The effect of facilitated tucking position during painful procedure in pain management of preterm infants in neonatal intensive care unit: a systematic review and meta-analysis

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

The effect of facilitated tucking and white noise on stress and sleep of newborns receiving nasal continuous positive airway pressure

OBJECTIVE

To investigate the effects of facilitated tucking and white noise on stress and sleep in neonates receiving nasal continuous positive airway pressure (CPAP).

METHOD

This study was conducted as a randomised controlled experimental study of neonates receiving nasal CPAP in neonatal intensive care units. The study sample consisted of 108 newborns (facilitated tucking (n = 36), white noise (n = 36) and control (n = 36)) receiving nasal CPAP support in the NICU. The neonates' sleep parameters were recorded by actigraphy for 24 h. Data were collected using the Neonatal Descriptive Information Form, the Sleep Tracking Form and the Neonatal Stress Scale. Percentage, mean, chi-squared and one-way ANOVA were used for data analysis.

RESULTS

It was found that 50.9% of the newborns were female, their mean gestational age was 33.54 ± 3.38, their mean height was 43.56 ± 5.12, and their mean weight was 2139.23 ± 827.82. The total sleep time of the neonates in the facilitated tucking and white noise group increased by 3 h, their sleep efficiency increased by 20% and their mean stress scores decreased (p < 0.05).

CONCLUSION

Facilitated tucking and white noise each showed a similar improvement in sleep duration and sleep efficiency and a reduction in stress scores in neonates receiving nasal CPAP. Close monitoring of sleep in this population and supportive care practices are recommended.

PRACTICE IMPLICATIONS

The findings of this study may help to reduce sleep problems and stress levels in the clinical care of neonates in the NICU through developmental nursing practices.

Application of the Adverse Childhood Experiences Framework to the NICU

BACKGROUND

Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families.

PURPOSE

Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment.

METHODS

An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed.

RESULTS

NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care.

Parental experience of neonatal pain research while participating in the Parental touch trial (Petal)

ABSTRACT

Parental involvement in neonatal comfort care is a core component of family-centred care. Yet, parents experience a range of positive and negative feelings when providing pain-relieving interventions for their infants. Parents of infants who participated in the Parental touch trial (Petal), a multicentre randomised controlled trial investigating the impact of gentle parental touch on neonatal pain, were asked to complete an anonymous survey. This survey aimed to (1) explore parent-reported motivations in deciding to participate in the Petal trial; (2) understand parent-reported experiences related to trial participation; (3) understand parents' willingness to participate in future studies; and (4) evaluate parent-reported feelings while they were delivering a gentle touch intervention either before or after a clinically necessary blood test. One hundred six parents (1 parent per infant) took part in the survey. Primary motivators for participation were altruistic. Parents most frequently reported that they wanted their child to take part in the research because it has a potential benefit to babies in the future and because they wanted to improve scientific understanding. Parents reported that providing gentle touch to their children during painful procedures was associated with positive emotions, such as feeling "useful" (64%) and "reassured" (53%). Furthermore, nearly all parents (98%) were pleased to have participated in the Petal trial and would consider, or maybe consider, participating in further research studies. These results underscore the importance of structuring trials around parental involvement and providing opportunities for parents to be involved in providing comfort to their infants during necessary painful clinical procedures.

Effect of non-pharmacological interventions on pain in preterm infants in the neonatal intensive care unit: a network meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of different non-pharmacological interventions for pain management in preterm infants and provide high-quality clinical evidence.

METHODS

Randomized controlled trials (RCTs) of various non-pharmacological interventions for pain management in preterm infants were searched from PubMed, Web of Science, Embase, and the Cochrane Library from 2000 to the present (updated March 2023). The primary outcome was pain score reported as standardized mean difference (SMD). The secondary outcomes were oxygen saturation and heart rate reported as the same form.

RESULTS

Thirty five RCTs of 2134 preterm infants were included in the meta-analysis, involving 6 interventions: olfactory stimulation, combined oral sucrose and non-nutritive sucking (OS + NNS), facilitated tucking, auditory intervention, tactile relief, and mixed intervention. Based on moderate-quality evidence, OS + NNS (OR: 3.92, 95% CI: 1.72, 6.15, SUCRA score: 0.73), facilitated tucking (OR: 2.51, 95% CI: 1.15, 3.90, SUCRA score: 0.29), auditory intervention (OR: 2.48, 95% CI: 0.91, 4.10, SUCRA score: 0.27), olfactory stimulation (OR: 1.80, 95% CI: 0.51, 3.14, SUCRA score: 0.25), and mixed intervention (OR: 2.26, 95% CI: 0.10, 4.38, SUCRA score: 0.14) were all superior to the control group for pain relief. For oxygen saturation, facilitated tucking (OR: 1.94, 95% CI: 0.66, 3.35, SUCRA score: 0.64) and auditory intervention (OR: 1.04, 95% CI: 0.22, 2.04, SUCRA score: 0.36) were superior to the control. For heart rate, none of the comparisons between the various interventions were statistically significant.

CONCLUSION

This study showed that there are notable variations in the effectiveness of different non-pharmacological interventions in terms of pain scores and oxygen saturation. However, there was no evidence of any improvement in heart rate.

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review

OBJECTIVE

The objective of this review was to evaluate the effectiveness of technology-based interventions for relieving procedural pain among hospitalized neonates compared with other non-pharmacological interventions.

INTRODUCTION

Neonates who require hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (eg, games, eHealth applications, mechanical vibrators) have become more commonplace in pediatric pain management over recent years; however, there is a sizeable knowledge gap around how effective technology-based interventions are for relieving pain in neonates.

INCLUSION CRITERIA

This review considered experimental trials that include technology-based, non-pharmacological interventions for relieving procedural pain among hospitalized neonates. The primary outcomes of interest include pain response to a procedure measured by a pain assessment scale validated for neonates, behavioral indicators, and changes in physiological indicators.

METHODS

The search strategy aimed to identify both published and unpublished studies. MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Cochrane Central Register of Controlled Trials, MedNar, and EBSCO Open Dissertations databases were searched for studies published in English, Finnish, or Swedish. Critical appraisal and data extraction were conducted by 2 independent researchers who adhered to JBI methodology. Meta-analysis could not be performed due to considerable heterogeneity in the studies; as a result, the findings are presented narratively.

RESULTS

A total of 10 randomized controlled trials involving 618 children were included in the review. The staff members delivering the interventions and the outcome assessors were not blinded in all of the studies, which introduced a potential risk of bias. The presented technology-based interventions were diverse, including laser acupuncture, noninvasive electrical stimulation of acupuncture points, robot platform, vibratory stimulation, recorded maternal voice, and recorded intrauterine voice. In the studies, pain was measured using validated pain scales, behavioral indicators, and physiological variables. In the studies in which pain was assessed with a validated pain measure (N=8), technology-based pain relief was significantly more effective than the comparator in 2 studies, whereas no statistically significant differences were observed in 4 studies and the technology-based intervention was less effective than the comparator in 2 studies.

CONCLUSIONS

The effectiveness of technology-based interventions in relieving neonatal pain, either as a standalone method or in combination with another non-pharmacological method, was mixed. Further research is needed to provide reliable evidence on which technology-based, non-pharmacological pain relief intervention is most effective for hospitalized neonates.

SUPPLEMENTAL DIGITAL CONTENT

A Finnish-language version of the abstract of this review is available as supplemental digital content [ http://links.lww.com/SRX/A19 ].

REVIEW REGISTRATION

PROSPERO CRD42021254218.

Opioids for procedural pain in neonates

BACKGROUND

Neonates might be exposed to numerous painful procedures due to diagnostic reasons, therapeutic interventions, or surgical procedures. Options for pain management include opioids, non-pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported.

OBJECTIVES

To evaluate the benefits and harms of opioids in term or preterm neonates exposed to procedural pain, compared to placebo or no drug, non-pharmacological intervention, other analgesics or sedatives, other opioids, or the same opioid administered by a different route.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was December 2021.

SELECTION CRITERIA

We included randomized controlled trials conducted in preterm and term infants of a postmenstrual age (PMA) up to 46 weeks and 0 days exposed to procedural pain where opioids were compared to 1) placebo or no drug; 2) non-pharmacological intervention; 3) other analgesics or sedatives; 4) other opioids; or 5) the same opioid administered by a different route.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods and any harms. We used a fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, and their confidence intervals (CI). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 13 independent studies (enrolling 823 newborn infants): seven studies compared opioids to no treatment or placebo (the main comparison in this review), two studies to oral sweet solution or non-pharmacological intervention, and five studies (of which two were part of the same study) to other analgesics and sedatives. All studies were performed in a hospital setting. Opioids compared to placebo or no drug Compared to placebo, opioids probably reduce pain score assessed with the Premature Infant Pain Profile (PIPP)/PIPP-Revised (PIPP-R) scale during the procedure (MD -2.58, 95% CI -3.12 to -2.03; 199 participants, 3 studies; moderate-certainty evidence); may reduce Neonatal Infant Pain Scale (NIPS) during the procedure (MD -1.97, 95% CI -2.46 to -1.48; 102 participants, 2 studies; low-certainty evidence); and may result in little to no difference in pain score assessed with the Douleur Aiguë du Nouveau-né (DAN) scale one to two hours after the procedure (MD -0.20, 95% CI -2.21 to 1.81; 42 participants, 1 study; low-certainty evidence). The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R scale up to 30 minutes after the procedure (MD 0.14, 95% CI -0.17 to 0.45; 123 participants, 2 studies; very low-certainty evidence) or one to two hours after the procedure (MD -0.83, 95% CI -2.42 to 0.75; 54 participants, 2 studies; very low-certainty evidence). The evidence is very uncertain about the effect of opioids on episodes of bradycardia (RR 3.19, 95% CI 0.14 to 72.69; 172 participants, 3 studies; very low-certainty evidence). Opioids may result in an increase in episodes of apnea compared to placebo (RR 3.15, 95% CI 1.08 to 9.16; 199 participants, 3 studies; low-certainty evidence): with one study reporting a concerning increase in severe apnea (RR 7.44, 95% CI 0.42 to 132.95; 31 participants, 1 study; very low-certainty). The evidence is very uncertain about the effect of opioids on episodes of hypotension (RR not estimable, risk difference 0.00, 95% CI -0.06 to 0.06; 88 participants, 2 studies; very low-certainty evidence). No studies reported parent satisfaction with care provided in the neonatal intensive care unit (NICU). Opioids compared to non-pharmacological intervention The evidence is very uncertain about the effect of opioids on pain score assessed with the Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale during the procedure when compared to facilitated tucking (MD -4.62, 95% CI -6.38 to -2.86; 100 participants, 1 study; very low-certainty evidence) or sensorial stimulation (MD 0.32, 95% CI -1.13 to 1.77; 100 participants, 1 study; very low-certainty evidence). The other main outcomes were not reported. Opioids compared to other analgesics or sedatives The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R during the procedure (MD -0.29, 95% CI -1.58 to 1.01; 124 participants, 2 studies; very low-certainty evidence); up to 30 minutes after the procedure (MD -1.10, 95% CI -2.82 to 0.62; 12 participants, 1 study; very low-certainty evidence); and one to two hours after the procedure (MD -0.17, 95% CI -2.22 to 1.88; 12 participants, 1 study; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of apnea during (RR 3.27, 95% CI 0.85 to 12.58; 124 participants, 2 studies; very low-certainty evidence) and after the procedure (RR 2.71, 95% CI 0.11 to 64.96; 124 participants, 2 studies; very low-certainty evidence) and on hypotension (RR 1.34, 95% CI 0.32 to 5.59; 204 participants, 3 studies; very low-certainty evidence). The other main outcomes were not reported. We identified no studies comparing different opioids (e.g. morphine versus fentanyl) or different routes for administration of the same opioid (e.g. morphine enterally versus morphine intravenously).

AUTHORS' CONCLUSIONS

Compared to placebo, opioids probably reduce pain score assessed with PIPP/PIPP-R scale during the procedure; may reduce NIPS during the procedure; and may result in little to no difference in DAN one to two hours after the procedure. The evidence is very uncertain about the effect of opioids on pain assessed with other pain scores or at different time points. The evidence is very uncertain about the effect of opioids on episodes of bradycardia, hypotension or severe apnea. Opioids may result in an increase in episodes of apnea. No studies reported parent satisfaction with care provided in the NICU. The evidence is very uncertain about the effect of opioids on any outcome when compared to non-pharmacological interventions or to other analgesics. We identified no studies comparing opioids to other opioids or comparing different routes of administration of the same opioid.

Effect of Acupoint Stimulation on Controlling Pain from Heel Lance in Neonates: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To evaluate the effect of acupoint stimulation compared to other interventions on pain control in neonates who underwent heel lance, we searched for randomized controlled trials across six databases (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, and Web of Science) published up to January 2023. Studies comparing acupoint stimulation and other interventions for controlling heel lance pain in neonates were included. These reports measured at least one of the following variables: pain score, crying time, oxygenation saturation, heart rate, respiration rate, and duration of the procedure. The data were independently extracted by two authors, and the PRISMA guidelines for study selection were followed. A total of 79 articles were screened, and 10 studies, with results on 813 neonates, were included in the final selection. The pain scores recorded during the heel lance procedure were not significantly different between the acupoint stimulation cohort and the control cohort (SMD of -0.26, 95% confidence interval (CI) from -0.52 to 0.01; p = 0.06; I² = 68%). After processing the subgroup analyses, significant differences were found in the comparisons of acupuncture vs. usual care (SMD of -1.25, 95% CI from -2.23 to 0.27) and acupressure vs. usual care (SMD of -0.62, 95% CI from -0.96 to -0.28); nonsignificant differences were found in other comparisons. Our results demonstrate that acupoint stimulation may improve pain score during the heel lance procedure.

Opioids for procedural pain in neonates

BACKGROUND

Neonates might be exposed to numerous painful procedures due to diagnostic reasons, therapeutic interventions, or surgical procedures. Options for pain management include opioids, non-pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported.

OBJECTIVES

To evaluate the benefits and harms of opioids in term or preterm neonates exposed to procedural pain, compared to placebo or no drug, non-pharmacological intervention, other analgesics or sedatives, other opioids, or the same opioid administered by a different route.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was December 2021.

SELECTION CRITERIA

We included randomized controlled trials conducted in preterm and term infants of a postmenstrual age (PMA) up to 46 weeks and 0 days exposed to procedural pain where opioids were compared to 1) placebo or no drug; 2) non-pharmacological intervention; 3) other analgesics or sedatives; 4) other opioids; or 5) the same opioid administered by a different route.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods and any harms. We used a fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, and their confidence intervals (CI). We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 13 independent studies (enrolling 823 newborn infants): seven studies compared opioids to no treatment or placebo (the main comparison in this review), two studies to oral sweet solution or non-pharmacological intervention, and five studies (of which two were part of the same study) to other analgesics and sedatives. All studies were performed in a hospital setting. Opioids compared to placebo or no drug Compared to placebo, opioids probably reduce pain score assessed with the Premature Infant Pain Profile (PIPP)/PIPP-Revised (PIPP-R) scale during the procedure (MD -2.58, 95% CI -3.12 to -2.03; 199 participants, 3 studies; moderate-certainty evidence); may reduce Neonatal Infant Pain Scale (NIPS) during the procedure (MD -1.97, 95% CI -2.46 to -1.48; 102 participants, 2 studies; low-certainty evidence); and may result in little to no difference in pain score assessed with the Douleur Aiguë du Nouveau-né (DAN) scale one to two hours after the procedure (MD -0.20, 95% CI -2.21 to 1.81; 42 participants, 1 study; low-certainty evidence). The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R scale up to 30 minutes after the procedure (MD 0.14, 95% CI -0.17 to 0.45; 123 participants, 2 studies; very low-certainty evidence) or one to two hours after the procedure (MD -0.83, 95% CI -2.42 to 0.75; 54 participants, 2 studies; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of bradycardia (RR 3.19, 95% CI 0.14 to 72.69; 172 participants, 3 studies; very low-certainty evidence). Opioids may result in an increase in episodes of apnea compared to placebo (RR 3.15, 95% CI 1.08 to 9.16; 199 participants, 3 studies; low-certainty evidence). The evidence is very uncertain about the effect of opioids on episodes of hypotension (RR not estimable, risk difference 0.00, 95% CI -0.06 to 0.06; 88 participants, 2 studies; very low-certainty evidence). No studies reported parent satisfaction with care provided in the neonatal intensive care unit (NICU). Opioids compared to non-pharmacological intervention The evidence is very uncertain about the effect of opioids on pain score assessed with the Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale during the procedure when compared to facilitated tucking (MD -4.62, 95% CI -6.38 to -2.86; 100 participants, 1 study; very low-certainty evidence) or sensorial stimulation (MD 0.32, 95% CI -1.13 to 1.77; 100 participants, 1 study; very low-certainty evidence). The other main outcomes were not reported. Opioids compared to other analgesics or sedatives The evidence is very uncertain about the effect of opioids on pain score assessed with the PIPP/PIPP-R during the procedure (MD -0.29, 95% CI -1.58 to 1.01; 124 participants, 2 studies; very low-certainty evidence); up to 30 minutes after the procedure (MD -1.10, 95% CI -2.82 to 0.62; 12 participants, 1 study; very low-certainty evidence); and one to two hours after the procedure (MD -0.17, 95% CI -2.22 to 1.88; 12 participants, 1 study; very low-certainty evidence). No studies reported any harms. The evidence is very uncertain about the effect of opioids on episodes of apnea during (RR 3.27, 95% CI 0.85 to 12.58; 124 participants, 2 studies; very low-certainty evidence) and after the procedure (RR 2.71, 95% CI 0.11 to 64.96; 124 participants, 2 studies; very low-certainty evidence) and on hypotension (RR 1.34, 95% CI 0.32 to 5.59; 204 participants, 3 studies; very low-certainty evidence). The other main outcomes were not reported. We identified no studies comparing different opioids (e.g. morphine versus fentanyl) or different routes for administration of the same opioid (e.g. morphine enterally versus morphine intravenously).

AUTHORS' CONCLUSIONS

Compared to placebo, opioids probably reduce pain score assessed with PIPP/PIPP-R scale during the procedure; may reduce NIPS during the procedure; and may result in little to no difference in DAN one to two hours after the procedure. The evidence is very uncertain about the effect of opioids on pain assessed with other pain scores or at different time points. No studies reported if any harms occurred. The evidence is very uncertain about the effect of opioids on episodes of bradycardia or hypotension. Opioids may result in an increase in episodes of apnea. No studies reported parent satisfaction with care provided in the NICU. The evidence is very uncertain about the effect of opioids on any outcome when compared to non-pharmacological interventions or to other analgesics. We identified no studies comparing opioids to other opioids or comparing different routes of administration of the same opioid.

A systematic review of improved positions and supporting devices for premature infants in the NICU

Background

In the neonatal intensive care unit, nurses often place premature infants in the supine, prone, and lateral positions. However, these positions do not always meet all the physiological needs of premature infants. Thus, many improved positions and various position-supporting devices have been studied to provide infants with a development-friendly and comfortable environment.

Aim

We aimed to help nurses recognize and understand the various improved positions and devices, and to provide nurses with more options in addressing the needs of preterm infants.

Study design

We searched PubMed, Web of Science, and EMBASE from 2012 to 2022 for studies on position management of preterm infants, and screened the search results according to inclusion and exclusion criteria. Then we extracted data and evaluated the quality of the included studies. Finally, we conducted a qualitative summary of the results.

Results

Twenty-one articles were included in this review. Fourteen were studies about improved positions, including hammock position, facilitated tucking position, ROP position, reverse kangaroo mother care position (R-KMC), and supported diagonal flexion position (SDF). Seven were studies on positioning devices, four on cranial deformity prevention, and three on reformative swaddling. They have a positive impact on sleep and flexion maintenance, in addition, they can prevent head deformity and reduce the pain of premature infants.

Conclusion

The position management of premature infants is diversified. Instead of sticking to a single position placement, nurses should adjust the position according to the unique physiological conditions of infants to reduce sequelae and promote their recovery and growth during long-term hospitalization. There should be more studies on position management with large sample sizes in the future.

[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.

Physiological Effects of Handling in Moderate to Late Preterm Infants Receiving Neonatal Intensive Care

BACKGROUND

Of all preterm births, approximately 82% are moderate to late preterm. Moderate to late preterm infants are often treated like full-term infants despite their physiological and metabolic immaturity, increasing their risk for mortality and morbidity.

PURPOSE

To describe the relationship between routine caregiving methods and physiological markers of stress and hypoxemia in infants born between 32 and 36 weeks' gestation.

METHODS

This descriptive study used a prospective observational design to examine the relationship between routine caregiving patterns (single procedure vs clustered care) and physiological markers of stress and hypoxemia such as regional oxygen saturation, quantified as renal and cerebral regional oxygen saturation (StO2), systemic oxygen saturation (Spo2), and heart rate (HR) in moderate to late preterm infants. Renal and cerebral StO2 was measured using near-infrared spectroscopy during a 6-hour study period. Spo2 and HR were measured using pulse oximetry.

RESULTS

A total of 231 procedures were captured in 37 participants. We found greater alterations in cerebral StO2, renal StO2, Spo2, and HR when routine procedures were performed consecutively in clusters than when procedures were performed singly or separately.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Our results suggest that the oxygen saturation and HR of moderate to late preterm infants were significantly altered when exposed to routine procedures that were performed consecutively, in clusters, compared with when exposed to procedures that were performed singly or separately. Adequately powered randomized controlled trials are needed to determine the type of caregiving patterns that will optimize the health outcomes of this vulnerable population.

Touch Experiences of Preterm Infants During Essential Nursing Care

Purpose: To characterize and quantify touch experienced by preterm infants in the NICU during essential nursing care, identify instances of skin-to-skin touch between infants and caregivers, and identify clinical/demographic variables associated with touch experiences. Design: Cross-sectional study. Sample: Preterm infants (N = 20) born 27-32 weeks post-menstrual age. Main Outcome Variable: Categories of touch during observations. Results: Touch experienced by infants during day and night shifts was primarily direct touch that was further categorized as general handling. During day shifts, 30 percent of direct touch was provided for comfort, but only 9.7 percent of touch was provided exclusively for comfort (i.e., without more intrusive touch). During night shifts, 10.6 percent of direct touch was provided for comfort, and 3 percent was categorized as exclusive comforting touch. Caregivers wore gloves for >89 percent of infant touch. Only the level of respiratory support was associated with touch categories during both shifts.

An integrative review of clinician-administered comforting touch interventions and acute stress responses of preterm infants

PROBLEM

Preterm infants experience numerous stressors in the neonatal intensive care unit. Non-pharmacological interventions, including maternal comforting touch, reduce stress responses of preterm infants; however, the effects of clinician-administered comforting touch are unclear. The purpose of this integrative review was to synthesize findings from clinical trials to determine the effect of clinician-administered comforting touch on preterm infants' acute stress responses.

ELIGIBILITY CRITERIA

Eligible clinical trials were published in English between 2001 and October 2021 and reported effects of clinician-administered comforting touch on acute stress responses in preterm infants.

SAMPLE

Thirty clinical trials were included.

RESULTS

Researchers tested the effect of comforting static touch, massage, massage with kinesthetic stimulation, sensorial saturation, and Yakson. There was significant heterogeneity in study design, comparison condition, and context of intervention delivery. Results varied; some studies demonstrated efficacy of comforting touch in reducing acute stress responses and others showed no effect. Generally, comforting touch provided during stressful procedures was associated with lower stress responses compared to standard care and was an effective adjunct to other stress management strategies. However, comforting touch alone was insufficient for managing pain, especially during skin-breaking procedures.

CONCLUSIONS

While comforting touch may be a useful part of stress management plans for preterm infants, additional research is needed to determine when comforting touch is appropriate and effective.

IMPLICATIONS

Comforting touch is beneficial to preterm infants and should be provided for stress management. For highly intrusive or painful procedures, comforting touch can be provided as part of a comprehensive stress management plan.

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.

Fifteen-minute consultation: Decision-making pathway for neonatal vascular access

Newborn infants admitted for neonatal intensive and high dependency care are reliant on intravenous therapy for medications, hydration and nutrition. Adopting a structured approach to gaining neonatal vascular access can improve efficiency and potentially reduce complications. In this article, we discuss an algorithm for decision-making in neonatal vascular access.

Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis

Background

Pain management is currently important in neonatal intensive care unit (NICU). The superiority in pain relief of the combined oral sucrose (OS) and nonnutritive sucking (NNS) to other single intervention has not been well established. The administration of sucrose has been considered to potentially induce adverse events, which has been controversial. This study aims to investigate the combined effects and safety in comparison with other single intervention methods, including NNS, OS alone, breast milk and oral glucose.

Methods

We searched databases including Medline (via Pubmed), Embase (via Ovid), web of science, and Cochrane Library for randomized controlled trials from Jan 1, 2000 to Mar 31, 2021. The data were analyzed in the meta-analysis using Review manager Version 5.3. Pain score was the primary outcome in this meta-analysis. The adverse events were assessed qualitatively.

Results

A total of 16 studies were eligible in the meta-analysis. The results demonstrated a significant reduction in pain score in the NNS+OS group compared with NNS alone (SMD = -1.69, 95%CI, -1.69,-0.65) or sucrose alone (SMD = -1.39, 95% CI, -2.21,-0.57) during the painful procedures. When compared NNS+OS with breast milk, no significant difference was detected (SMD = -0.19, 95% CI: -0.5, 0.11).

Conclusion

The combined effects of NNS and OS might be superior to other single intervention method. However, the effects might be mild for moderate-to-severe pain.

The Effect of Endotracheal Suctioning Using the Four-handed Care on Physiological Criteria and Behavioral Responses of the Preterm Infants: Randomized Crossover Clinical Trial

Introduction: Endotracheal suctioning is one of the procedures that can cause pain and stress for infants admitted to neonatal intensive care units (NICUs). Pain and stress can be manifested with physiological and behavioral responses. This study is a crossover randomized clinical trial design that aimed to investigate the effect of endotracheal suctioning, using four-handed care on the physiological criteria and behavioral responses of preterm infants. Methods: In this study, 40 infants were randomly divided into two groups of 20, one group was first suctioned by the routine method (two hands) and then with the four-handed method. The other group was first suctioned by the four-handed method and then with the routine one. The ALPS-Neo (Astrid Lindgren Children’s Hospital Pain Scale Neonates) was used to evaluate pain and stress in infants. One camera recorded facial expressions and body movements, and physiological data were recorded from the monitor simultaneously. Results: Repeated measures analysis of variance (ANOVA) showed no statistically significant difference in changes in arterial saturation, heart rate and behavioral response scores between the two methods, but there was a significant difference in the mean heart rate of infants during and two minutes after suctioning in four-handed method using independent t test. Data were analyzed using SPSS version 13. Conclusion: Four-handed suctioning method can prevent an increase in the heart rate during and two minutes after suctioning, but it does not seem to affect behavioral responses and oxygen saturation of the infants. Since one of the symptoms of pain and stress in infants is the change of vital signs, especially the heart rate, we recommend four-handed method for suctioning of endotracheal tube.

The Effect of Breastfeeding, Kangaroo Care, and Facilitated Tucking Positioning in Reducing the Pain During Heel Stick in Neonates

PURPOSE

Invasive intervention can negatively affect prognosis, behavior, environmental adaptation in neonates. Some nonpharmacological pain management methods are used for effective pain treatment. This study investigated the effect of breastfeeding, kangaroo care, and facilitated tucking positioning on heel-stick pain in neonates.

DESIGN

A quasi-experimental design was employed. The study was conducted in three family health centers in Kütahya/Turkey. The sample consisted of 140 healthy neonates with the gestational age of 37 weeks or more, birth weight greater than 2500 g, and no sucking problems. The sample was divided into four groups (breastfeeding, kangaroo care, facilitated tucking position, and control). Data were collected using a Baby-Mother Characteristics Questionnaire, a Physiological Parameter Follow-up Form, and the Neonatal Infant Pain Scale. Data were analyzed using chi-square, the one-way analysis of variance (ANOVA), Kruskal-Wallis, Student t-test, and Mann-Whitney U tests. The research adhered to ethical principles.

RESULTS

The facilitated tucking position group cried less and experienced less pain during heel stick than the other groups (p < 0.05). Breastfeeding, kangaroo care, and facilitating tucking help reduce heel-stick pain but facilitating tucking causes less crying and imposes less pain on neonates than the other methods.

CONCLUSION

Facilitated tucking position may be preferred to reduce pain during heel stick.

PRACTICE IMPLICATIONS

Using facilitated tucking positions and breastfeeding methods can assist healthcare professionals as supportive methods in pain management.

Painful procedures and pain management in newborns admitted to an intensive care unit

OBJECTIVE

To characterize painful procedures, analgesic strategies, vital signs, and pain scores in hospitalized newborns.

METHOD

This is a primary, observational, prospective clinical study, developed in a Brazilian public hospital. Demographic data, painful procedures, pain relief measures, vital signs, and pain scores were collected from the clinical records of 90 newborns admitted to the intensive care unit and evaluated between admission and the third day of admission. For statistical analysis, the software Statistic Package for the Social Sciences and the R Software were used.

RESULTS

Newborns underwent 2,732 painful procedures, 540 non-pharmacological and 216 pharmacological strategies. The most frequently performed procedure was the heel prick (20.96%). The most commonly recorded non-pharmacological strategy was dim lighting (28.33%) and continuous fentanyl (48.83%) was the main pharmacological measure adopted. Pain score and vital signs show variability in the period evaluated.

CONCLUSION

Despite the high number of painful procedures, pain assessment records do not reflect procedural pain and the use of analgesic strategies was insufficient.

Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies

Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.

Pain in Preterm Infants: Different Perspectives

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

Sedoanalgesia in neonatal units

Pain recognition and management continues to be a challenge for health professionals in Neonatal Intensive Care Units. Many of the patients are routinely exposed to repeated painful experiences with demonstrated short- and long-term consequences. Preterm babies are a vulnerable high-risk population. Despite international recommendations, pain remains poorly assessed and managed in many Neonatal Intensive Care Units. Due to there being no general protocol, there is significant variability as regards the guidelines for the approach and treatment of pain between the different Neonatal Intensive Care Units. The objective of this article is to review and assess the general principles of pain in the initial stages of development, its recognition through the use of standardised scales. It also includes its prevention and management with the combination of pharmacological and non-pharmacological measures, as well as to establish recommendations that help alleviate pain in daily clinical practice by optimising pain and stress control in the Neonatal Intensive Care Units.

Effects of Temperature and Position Change on Neonatal Brain Regional Oxygen Saturation in Tub Bathing: A Prospective Study

INTRODUCTION

A major goal in neonatal medicine is to reduce stress as much as possible in routine care. Bathing is one of the important routine cares for neonates, but it makes a big environmental change for them. We aimed to examine whether water temperature, room temperature, and position changes in tub bathing serve as noxious stimuli to neonates.

METHODS

This prospective trial was performed in full-term and non-low-birth-weight neonates admitted to the hospital between July 2020 and March 2021. Those with underlying diseases, fetal distress, infection, and other medical conditions were excluded. Measurements were taken during the neonates' first tub bath since birth, which was performed by a trained nurse. Changes in regional oxygen saturation (rSO₂), determined using near-infrared spectroscopy, and water and room temperature, were examined at five different time points: upon entering the bath, head washing, position change, exiting the bath, and during the 3 min after bathing.

RESULTS

In total, 17 neonates were analyzed. No changes in rSO₂ due to head washing or position change were observed; however, rSO₂ significantly decreased upon entering (78.5 ± 4.1% vs. 75.7 ± 4.1%, p < 0.001) and exiting the bath (75.8 ± 5.7% vs. 74.4 ± 5.4%, p < 0.04). The rate change in rSO₂ upon entering the bath showed a significant inverse correlation with water temperature (r =  - 0.53, p < 0.03), and there were no significant correlations between rSO₂ and water or room temperature upon exiting the bath. There was no change in body skin temperature before and after bathing, but rSO₂ gradually decreased during the 3 min after bathing.

CONCLUSIONS

Neonates may perceive certain temperatures during bathing as noxious stimuli. Therefore, methods to minimize stress associated with bathing should be implemented to reduce the difference between water temperature and room temperature during bathing.

TRIAL REGISTRATION

This trial has been registered at UMIN repository with the trial number UMIN000041045 ( https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046500 ). The date of the final dataset was April 01, 2021.

Knowledge, attitudes and practices of neonatal professionals regarding pain management

Pain management is an important issue which impacts the prognosis of neonates in neonatal intensive care units. Evidence has shown that professionals' knowledge and attitudes regarding pain management can impact the quality of their practice. The purpose of this study was to evaluate the knowledge, attitudes, and practices of neonatal professionals regarding neonatal pain management. A cross-sectional study was performed involving neonatal physicians and nurses, using a research questionnaire to investigate the knowledge and attitudes of professionals as well as to assess their practice of pain management. Research found an apparent discrepancy between the knowledge levels of neonatologists and nurses regarding pain assessment and management, with nurses displaying weaker professional knowledge and more negative attitudes toward pain management than did neonatologists. Additionally, research revealed a lack of knowledge and negative attitudes among participants regarding the provision of sufficient opioid analgesics to sick infants during invasive procedures and even for dying neonates. There is an urgent need for continuing education regarding neonatal pain management with the goal of empowering neonatal professionals; further research is needed into the question of how to translate education into more reliable practice.Conclusion: This research provides useful information regarding the knowledge, attitudes, and clinical practice of neonatal pain management among neonatologists and nurses and points out some differences in the knowledge levels of these two groups. What is Known: •Neonates can perceive and respond to pain stimuli by showing their biological signals similarly to children and adults. •Untreated or insufficient pain management for high-risk neonates has short-term. negative effects and may also induce long-term negative effects. What is New: •The level of knowledge, the attitudes, and the practices regarding neonatal pain in intensive care are different among neonatal professionals. •There is an urgent need to provide interdisciplinary continuing education to improve the knowledge of neonatal professionals and encourage them to more highly prioritize neonatal pain management.

Comparison the Effect of Breast Milk Smell, White Noise and Facilitated Tucking Applied to Turkish Preterm Infants During Endotracheal Suctioning on Pain and Physiological Parameters

PURPOSE

This study aimed to determine the effect of the breast milk smell, white noise and facilitated tucking during endotracheal suctioning (ES) on pain and physiological findings.

DESIGN AND METHODS

The present study was conducted as a randomized, controlled experimental trial study. The sample of the study was composed of a total of 80 preterm infants. Pain was measured with PIPP-R pain scale. rMANOVA and bonferroni tests were used in the comparison of the pain scores of the groups.

RESULTS

It was determined that white noise and facilitated tucking were more effective in relieving infants before ES procedure (p < .05). No statistically significant difference was found between the groups in reducing the pain during ES procedure (p > .05). After the procedure, facilitated tucking was determined more effective in the recovery of preterm infants (p < .05).

PRACTICE IMPLICATIONS

It is recommended to use facilitated tucking and white noise for decreasing pain of ventilated preterm infants during the ES procedure.

CONCLUSIONS

White noise and facilitated tucking were effective in relieving pain before procedure and facilitated tucking recovery in preterm infants after the ES procedure.