Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units

Magnetic Non-invasive Auricular Acupuncture During Eye-Exam for Retinopathy of Prematurity in Preterm Infants: A Multicentre Randomized Controlled Trial

Background: Eye exam for Retinopathy of prematurity (ROP) is a painful procedure and pharmacological analgesia might be ineffective. We hypothesized that magnetic auricular acupuncture (MAA) compared to placebo will decrease pain during ROP exam in preterm infants. Methods: Multicentre randomized controlled trial conducted in three hospitals (Australia, Canada, and Malaysia). Eligibility: >32 weeks, ROP exam, not sedated, and parental consent. A total of 100 infants were randomized (1:1) to MAA (n = 50) or placebo (n = 50). MAA stickers or placebo were placed on both ears by an unblinded investigator. Pain was assessed using the Premature Infant Pain Profile. Primary analyses were by intention-to-treat. ClinicalTrials.gov:NCT03650621. Findings: The mean (standard deviation, SD) gestation, birthweight, and postnatal age were (MAA 28(3) vs. placebo 28(2) weeks; MAA 1,057(455) vs. placebo 952(273) g; MAA 7(3) vs. placebo 7(3) weeks. Placebo infants had significantly higher PIPP scores during [mean difference 1.6 points (95%CI 0.1-3.1)] and 1 h mean difference 1.5 points (95%CI 0.7-2.2) after the procedure (p < 0.03). Heart rate was lower (173(22) vs. 184(18)/min) and oxygen saturations were higher (93.8(6.2) vs. 91.7(6.1)%, p = 0.05) in MAA infants. No adverse effects. Interpretation: MAA may reduce physiological pain responses during and after ROP exam in preterm infants. Assessment of long-term effects are warranted. Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT03650621.

Nursing management of children's pain: Current evidence and future directions for research

This critical literature review discusses the research evidence underpinning each of the pain standards in the National Service Framework for Children: Standard for hospital services. Relevant evidence-based reviews and clinical practice guidelines are highlighted, and aspects of children's pain management where the research evidence is particularly strong or weak are identified. Priorities are suggested for nurse-led research aimed at generating new knowledge to improve pain management for children.

Intraurethral Lidocaine for Urethral Catheterization in Children: A Randomized Controlled Trial

OBJECTIVES

To determine whether lidocaine is superior to nonanesthetic lubricant (NAL) for relieving pain in children undergoing urethral catheterization (UC).

METHODS

Children 0 to 24 months requiring UC were randomized to NAL or topical and intraurethral 2% lidocaine gel. Primary outcome was facial grimacing in the pre to during drug administration and catheterization phases. Secondary outcome was caregiver satisfaction by using a Visual Analog Scale.

RESULTS

There were 133 participants (n = 68 lidocaine, n = 65 NAL). There were no significant differences in mean (SD) scores during UC between lidocaine and NAL (86.4% [121.5%] vs 85.2% [126.6%]), respectively (Δ [confidence interval (CI)] = -1.2 [-21.0 to 49.0], P = .4). There was a significantly greater difference in mean (SD) scores during instillation of lidocaine versus NAL (61.8% [105.6%] vs 3.2% [84.9%]), respectively (Δ [CI] -58.6 [-95.0 to -32.0], P < .001). There were no significant differences in mean (SD) parental satisfaction scores between lidocaine and NAL (4.8 [3.2] vs 5.9 [2.9]), respectively (CI-0.1 to 2.2; P = .06). In the subgroup analysis, age, gender, and positive urine culture did not significantly influence between-group differences in facial grimacing.

CONCLUSIONS

Compared with NAL, topical and intraurethral lidocaine is not associated with significant pain reduction during UC, but significantly greater pain during instillation. Therefore, clinicians may consider using noninvasive pain-reducing strategies for young children who require UC.

COVERS Neonatal Pain Scale: Development and Validation

Newborns and infants are often exposed to painful procedures during hospitalization. Several different scales have been validated to assess pain in specific populations of pediatric patients, but no single scale can easily and accurately assess pain in all newborns and infants regardless of gestational age and disease state. A new pain scale was developed, the COVERS scale, which incorporates 6 physiological and behavioral measures for scoring. Newborns admitted to the Neonatal Intensive Care Unit or Well Baby Nursery were evaluated for pain/discomfort during two procedures, a heel prick and a diaper change. Pain was assessed using indicators from three previously established scales (CRIES, the Premature Infant Pain Profile, and the Neonatal Infant Pain Scale), as well as the COVERS Scale, depending upon gestational age. Premature infant testing resulted in similar pain assessments using the COVERS and PIPP scales with an r = 0.84. For the full-term infants, the COVERS scale and NIPS scale resulted in similar pain assessments with an r = 0.95. The COVERS scale is a valid pain scale that can be used in the clinical setting to assess pain in newborns and infants and is universally applicable to all neonates, regardless of their age or physiological state.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

Pain management and the effect of guidelines in neonatal units in Austria, Germany and Switzerland

BACKGROUND

Painful invasive procedures are frequently performed on preterm infants admitted to a neonatal intensive care unit (NICU). The aim of the present study was to investigate current pain management in Austrian, German and Swiss NICU and to identify factors associated with improved pain management in preterm infants.

METHODS

A questionnaire was sent to all Austrian, German and Swiss pediatric hospitals with an NICU (n = 370). Pain assessment and documentation, use of analgesics for 13 painful procedures, presence of written guidelines for pain management and the use of 12 analgesics and sedatives were examined.

RESULTS

A total of 225 units responded (61%). Pain assessment and documentation and frequent analgesic therapy for painful procedures were performed more often in units using written guidelines for pain management and in those treating >50 preterm infants at <32 weeks of gestation per year. This was also the case for the use of opioid analgesics and sucrose solution. Non-opioid analgesics were used more often in smaller units and in units with written guidelines. There was a broad variation in dosage of analgesics and sedatives within all groups.

CONCLUSION

Pain assessment, documentation of pain and analgesic therapy are more frequently performed in NICU with written guidelines for pain management and in larger units with more than 50 preterm infants at <32 weeks of gestation per year.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

State of the science: procedural pain management in the neonate

Neonates in the neonatal intensive care unit experience painful procedures. Over the last 10 years, investigators have examined several pharmacologic and nonpharmacolgic treatment strategies to decrease or eliminate the pain associated with mechanical ventilation, endotrachial intubation, insertion of percutaneous or central venous lines, heel stick, and venipuncture. These procedures and others are addressed as well as the reported severity of pain associated with these procedures. Progress has been made in the past decade to establish evidence-based treatments that will help the clinician more effectively relieve neonatal stress and pain when performing many routine procedures.

Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial

OBJECTIVE

Bladder catheterization (BC) is a commonly performed, painful procedure in the pediatric emergency department (ED). A survey demonstrated that analgesia is infrequently used for several brief painful procedures, including BC, in pediatric patients. In this study, we evaluated the use of 2% lidocaine gel to alleviate the pain associated with BC in young children (<2 years) in the ED.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial comparing pain scores during bladder catheterization with 2% lidocaine gel versus nonanesthetic lubricant. We used a previously validated scale for measuring brief procedure-related pain in preverbal children (Face Legs Arms Cry Consolability Pain Scale [FLACC]). A total of 115 patients were recruited; 56 patients were randomized to the control group, and 59 were randomized to the lidocaine group. Lubricant was applied to both the genital mucosa and the catheter. Pain measurements were recorded at 3 time intervals: before insertion of the catheter, during catheterization, and after catheterization. Interobserver reliability had been previously established in an observational pilot study.

RESULTS

The difference in mean FLACC scores between the control (7.55 +/- 2.56) and study groups (7.37 +/- 2.87) during catheterization was not statistically significant. The change in FLACC from time 1 (preprocedure) to time 2 (during procedure) was statistically significant in both groups, suggesting that bladder catheterization is a painful procedure.

CONCLUSIONS

Altering the standard practice of use of nonanesthetic lubricant with 2% lidocaine gel as lubricant during bladder catheterization in young children may not be helpful in alleviating the pain associated with the procedure.

The challenges of pain measurement in critically ill young children: A comprehensive review

This article addresses the issues in measuring pain in critically ill children, provides a comprehensive review of the pain measures for children aged between 0 and 3 years, and discusses their applicability to this group of children. When children are critically ill, pain can only exacerbate the stress response that already exists, to the extent that homeostasis cannot be maintained. Severity of illness is thus likely to affect physiologic and behavioural pain responses that would normally be demonstrated in healthy children. The problem of differentiating pain from other constructs adds to the complexity of assessing pain in non-verbal children. A pain measure to be useful clinically must be adapted to the developmental age of the target population. Search of electronic databases and other electronic sources was supplemented by hand review of relevant journals to identify published and unpublished pain measures for use in children aged between 0 and 3 years. Twenty eight pain measures were identified in the literature; 11 for neonates only, 11 for children aged between 0 and 3 years, and six for children more than 12 months. These measures vary in relation to their psychometric properties, clinical utility and the context in which the study was performed. These measures may not be suitable for the critically ill young child, because the items included were derived from observations of healthy or moderately sick children, and may not reflect pain behaviour in those who are critically ill. It is therefore recommended to develop new pain scales for this population of compromised children.

Comparison of oral glucose and sucrose solutions on pain response in neonates

In this study, we aimed to compare the analgesic effect of 30% sucrose and 10% and 30% glucose in a group of healthy term newborns. A total of 113 infants whose heels were pricked for the guthrie test were included in the study. The babies were randomized into 4 groups, receiving 2 ml of 30% sucrose, 10% glucose, 30% glucose, or distilled water. Response to pain was assessed by mean crying time, recovery time, maximum heart rate, and percent change in heart rate at 1, 2, and 3 minutes. Mean crying times were 60, 102, 95, and 105 seconds in the sucrose, 10% glucose, 30% glucose, and placebo groups, respectively (P =.02). Although mean recovery time was shorter in the sucrose group (102 seconds), there was neither a significant difference between the groups (10% glucose, 121 seconds; 30% glucose, 109 seconds; control group, 132 seconds [P =.09]), Nor was there a difference in maximum heart rate and percent change in heart rate at 1, 2, and 3 minutes after heel prick (P =.14, P =.05, P =.53 For the first, second, and third minutes, respectively ). However, a statistically borderline difference existed at the end of 2 minutes favoring sucrose (P =.05). We conclude that 30% sucrose is superior to 10% and 30% glucose solutions in relieving pain, showing its primary effect in crying time. As glucose solutions are readily available in neonatal intensive care units and easier to use in routine practice, further trials are needed to evaluate the antinociceptive effect of glucose when combined with other nonpharmacologic methods.

Sweet solutions and pacifiers for pain relief in newborn infants

In this study we aimed to assess and compare the analgesic effects of orally administered sucrose, dextrose, dextrose or sucrose followed by a pacifier, and sterile water during minor painful procedures in neonates. One hundred thirty-eight healthy term newborn infants were enrolled in this prospective study. They received either sweet solutions or sweet solutions followed by pacifiers before the heel prick (group 1, dextrose 12.5%; group 2, dextrose 12.5% followed by a pacifier; group 3, sucrose 12.5%; group 4, sucrose 12.5% followed by a pacifier; and group 5, sterile water). The median values for crying time and the pain scores performed according to the neonatal facial coding system were recorded. The median crying times were 16.5, 55, 92.5, 102, and 132 seconds in groups 4, 2, 3, 1, and 5, respectively (P = .0001). The pain scores showed that babies in group 4 had significantly lower scores followed by groups 2, 3, 1, and 5 (P = .0001). Although group 4 had a lower pain score and shorter crying time than group 2, the difference was not statistically significant (P = .27 and P = .39). In conclusion, 12.5% dextrose or sucrose followed by a pacifier was found to be superior to dextrose only and sucrose only solutions in pain relief; sucrose followed by a pacifier resulted in lower pain scores and shorter crying time than dextrose when combined with a pacifier. The antinociceptive effect of sweet solutions can be enhanced with a pacifier.

Pain and stress management in the Neonatal Intensive Care Unit — A national survey in Austria

Neonates are sensitive to pain and vulnerable to both its short-term and long-term effects. Management of analgesia is thought to be hampered by lack of awareness that newborns are capable of experiencing pain and by fears about adverse effects associated with analgesics. The purpose of this study was to assess current medical practice in preventive analgesia and sedation in the neonate throughout Austria. This report details the results of a survey in 28 neonatal intensive care units (NICUs) in Austria. Data collection took place from October to December 2001. All NICUs reported the capability of newborns to experience and express pain and nearly all stated the possibility of pain affecting morbidity. Validated scores for pain assessment were used by 11% of NICUs, standardized protocols for analgesia existed in 75%, and 100% practiced non-pharmacological treatment strategies. The use of preventive measures in routinely performed painful procedures ranged from 8% to 96%. For example, only 8% of NICUs prevent distress and pain prior to umbilical vessel catheterization, 29% prior to subcutaneous injections and 46% prior to heel lancing. Nearly all NICUs apply analgesia before lumbar puncture and thoracic-drain placement, and all use analgesic and/or sedative medication in elective intubation.

CONCLUSION

There is widespread awareness among neonatologists of the importance and effects of distress caused by pain in newborns. However, the necessity of providing sufficient analgesia is underestimated. Further information on the safety of analgesic drugs in neonatology is imperative.

Our youngest patients' pain--from disbelief to belief?

Though human pain has existed since the dawn of time, formal medical pain relief in the form of anesthesia and analgesia has been available only since the mid-nineteenth century. Even after these measures became available, they were used very selectively for the first 100 years of their existence. The youngest patients, especially, were denied pain relief, probably because they could not complain about their pain as articulately and as effectively as adult patients could. A desperate need existed for health care professionals to recognize and appreciate the fact that their youngest patients could suffer immensely and to adequately address the issue. This article reviews the evolution of knowledge and attitudes regarding young patients' pain and addresses why and how this process occurred. The evolution of knowledge was traced by reviewing the literature found in MEDLINE, CINAHL, and LEXIS-NEXIS searches and through hand searches of articles that were frequently cited. Physiologic, pharmacologic, ethical, and psychologic aspects of young patients' pain are addressed. A unique phenomenon arose from the data reviewed. The process of belief and changes in practice were encouraged not only by advances in science, but also by consumer demand. Advances in the past decade in the management of young patients' pain were profound, but are still not complete. Understanding the evolution surrounding pain recognition in young patients provides a stepping stone that can facilitate further improvements in the management of pain in young patients.

Effects of perinatal pain and stress

Neonatal intensive care exposes preterm neonates to a series of repeated, randomly occurring invasive procedures and handling, resulting in acute pain, chronic pain, and prolonged stress during a critical window associated with epochal brain development. Characteristics of the immature pain system in preterm neonates (such as a low pain threshold, prolonged periods of windup, overlapping receptive fields, immature descending inhibition) predisposes them to greater clinical and behavioral sequelae from inadequately treated pain than older age groups. Evidence for developmental plasticity in the neonatal brain suggests that repetitive painful experiences during this period or prolonged exposure to analgesic drugs may alter neuronal and synaptic organization permanently. Traditionally, clinicians have chosen the perspective that routine use of analgesic or sedative drugs in preterm neonates may create more problems than minimal therapy. However, the immediate and long-term consequences of inadequately treated pain have forced them to reconsider the risk-benefit ratios for such therapy. Whereas the short-term consequences of prolonged analgesic therapy in human neonates are well-known (tolerance, withdrawal, ventilator dependency), long-term consequences are relatively unknown. Advances in the study of repetitive pain associated with routine NICU care have challenged the perspective that prolonged pain and stress were inevitable consequences of premature birth.

Pain in hospitalized children: pediatric nurses' beliefs and practices

A descriptive design was used to gather information regarding nurses' beliefs and documentation practices related to pain assessment and management in children. Pediatric nurses (n = 260) from eight hospital units completed a child and pain survey. Nurses' pain-related documentations on children (n = 153) were also examined. Results showed inconsistency between what nurses believe about pain assessment and management and their documentation of practice. Nurses believed that assessment is the first step toward alleviating pain in children. However, it was not evident in their documentations that nurses used developmentally appropriate tools for assessment or for evaluation of children's responses to pain management strategies.

Randomised controlled trial of low dose fentanyl infusion in preterm infants with hyaline membrane disease

AIM

To evaluate the effects of low dose fentanyl infusion analgesia on behavioural and neuroendocrine stress response and short term outcome in premature infants ventilated for hyaline membrane disease.

METHODS

Twenty seven ventilated preterm infants were randomly assigned to receive a mean fentanyl infusion of 1.1 (0.08 SE) micrograms/kg/h for 75 (5) hours, and 28 untreated infants were considered a control group. A behavioural sedation score was used to assess the infants' behaviour. Urinary metanephrine and the normetanephrine:creatinine molar ratio were determined at 0, 24, 48 and 72 hours. Outcome data and ventilatory indexes were recorded for each infant.

RESULTS

The fentanyl group showed significantly lower behavioural stress scores and O2 desaturations than controls and lower urinary concentrations of metanephrine and normetanephrine at 24, 48, 72 hours. The two groups showed no significant difference in ventilatory variables or short term outcome.

CONCLUSIONS

A short course of low dose fentanyl infusion reduces behavioural sedation scores, O2 desaturations and neuroendocrine stress response in preterm ventilated infants.

Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants

AIM

To assess the safety and efficacy of EMLA cream (eutectic mixture of local anaesthetics) used to induce surface anaesthesia for venepuncture in healthy preterm infants.

METHODS

Nineteen infants, median gestational age 31 weeks (range 26-33 weeks) were assessed in a randomised, double blind, placebo controlled, cross-over trial. Changes in physiological variables (heart rate, blood pressure, oxygen saturation) and behavioural responses (neonatal facial coding system score, crying time) before and after venepuncture with EMLA cream were compared with those obtained with a placebo cream to assess efficacy. Toxicity was assessed by comparing methaemoglobin concentrations at 1 hour and 8 hours after application.

RESULTS

There was no significant difference in efficacy between EMLA and placebo creams in physiological and behavioural responses. There was no significant difference in methaemoglobin concentrations one hour after the cream had been applied. At eight hours, however, concentrations were significantly higher after EMLA than placebo (p = 0.016). There was no evidence of clinical toxicity.

CONCLUSION

This study does not support the routine use of EMLA for venepuncture in healthy preterm infants.

A cross-sectional survey of pain and pharmacological analgesia in Canadian neonatal intensive care units

OBJECTIVE

To determine current practices for the use of analgesia term and preterm neonates cared for in Neonatal Intensive Care Units (NICUs).

DESIGN

One-week survey of medical charts of current patients.

SETTING

NICUs in Canada.

PARTICIPANTS

A total of 14 of 38 invited NICUs participated. These units were not different on number of beds, admissions per year, or university affiliation from the nonparticipating units.

MAIN OUTCOME MEASURES

Daily logs were kept of the frequency and type of procedures and analgesia administration for all ill neonates in each NICU during the study period.

RESULTS

The sample consisted of 239 patients. A total of 2,134 invasive procedures were performed. Medication was given specifically 18 times for 17 invasive procedures (0.8%). For another 129 invasive procedures, the patient was receiving analgesia for reasons other than the procedure. Sixteen patients had surgery during the survey period, and another 14 had surgery prior to but within 4 days of the survey. Fifty-one patients received anaesthesia or analgesia specifically related to surgery (39 times), procedures (35 times), or other reasons (34 times), a total of 108 courses. Opioids were the most frequently used medications and were given for all reasons, by continuous infusion, intermittent bolus, or sometimes both methods for the same patient.

CONCLUSIONS

Postoperative pain in neonates in Canadian NICUs appears to be consistently treated, primarily with opioid analgesics, but analgesia, opioid or nonopioid is rarely given for nonsurgical invasive procedures.

Social barriers to optimal pain management in infants and children

OBJECTIVE

To examine the social barriers that lead to less than optimal management of pain in children.

DESIGN

Recognizing the vulnerabilities of infants and children and their dependence on caring adults, a model of pain communication is proposed. The model examines (a) the pain experiences of children, including social determinants; (b) developmental variations in the capacity to encode the severity and qualities of pain as expressive behavior; (c) adult skills and deficiencies in decoding pain; and (d) the actions of adults predicated on the meaning and significance attached to children's actions. Limitations in care were examined.

DATA SOURCES

The current research and professional literature were accessed through searches of the Psyclit and Medline databases for relevant investigations on the basis of our working knowledge of the literature.

CONCLUSION

Numerous deterrents to optimal care are identified in the domains of commonplace beliefs about the nature of pain in infants and children: failure to recognize the impact of socialization in familial and cultural modes of experience and expression; needs for age-specific assessment instruments; the limited capacity to use available evidence concerning pain; the need to employ clinicians, parents, and other adults more effectively in delivering care; and structural problems in the health care system.

Exposure to invasive procedures in neonatal intensive care unit admissions

The nature and numbers of invasive procedures were studied in 54 consecutive infants admitted to a neonatal intensive care unit. Over 3000 procedures were recorded, 74% in infants below 31 weeks of gestation. One infant (23 weeks' gestation, birth weight 560 g) underwent 488 procedures. Heel prick blood sampling was the most common procedure (56%), followed by endotracheal suction (26%) and intravenous cannula insertion (8%). Invasive procedures which would cause pain or distress to a child are frequently performed on infants admitted to the neonatal intensive care unit. A reduction in the number of procedures, modifying them, or providing adequate analgesia could relieve some of this pain and distress.