Assessment of pain in the neonate

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.

A Scientometric Review of Infant Cry and Caregiver Responsiveness: Literature Trends and Research Gaps over 60 Years of Developmental Study

Infant cry is an adaptive signal of distress that elicits timely and mostly appropriate caring behaviors. Caregivers are typically able to decode the meaning of the cry and respond appropriately, but maladaptive caregiver responses are common and, in the worst cases, can lead to harmful events. To tackle the importance of studying cry patterns and caregivers' responses, this review aims to identify key documents and thematic trends in the literature as well as existing research gaps. To do so, we conducted a scientometric review of 723 documents downloaded from Scopus and performed a document co-citation analysis. The most impactful publication was authored by Barr in 1990, which describes typical developmental patterns of infant cry. Six major research thematic clusters emerged from the analysis of the literature. Clusters were renamed "Neonatal Pain Analyzer" (average year of publication = 2002), "Abusive Head Trauma" (average year of publication = 2007), "Oxytocin" (average year of publication = 2009), "Antecedents of Maternal Sensitivity" (average year of publication = 2010), "Neurobiology of Parental Responses" (average year of publication = 2011), and "Hormonal Changes & Cry Responsiveness" (average year of publication = 2016). Research clusters are discussed on the basis of a qualitative inspection of the manuscripts. Current trends in research focus on the neurobiology of caregiver responses and the identification of factors promoting maternal sensitivity. Recent studies have also developed evidence-based strategies for calming crying babies and preventing caregivers' maladaptive responses. From the clusters, two topics conspicuously call for future research: fathers' responsiveness to infant cry and the impact of caregiver relationship quality on cry responsiveness.

Implementierung eines neonatalen Schmerzassessmentinstruments auf einer neonatologischen Intensivstation - Ein Qualitätsentwicklungsprojekt

Implementation of a Neonatal Pain Assessment Instrument at a Neonatal Intensive Care Unit - A Quality Improvement Project Abstract. Background: Optimal pain management is necessary in order to not jeopardize the development of preterm neonates. Aim: Implementation and evaluation of systematic and best possible pain assessment with the Bernese Pain Scale for Neonates for all preterm and sick neonates of a neonatal intensive care unit by nursing staff. Methods: The educational concept is based on three key strategies: knowledge translation (group- and one-on-one training), reflection (case conferences) and clinical training. The frequency of the use of the Pain Score was recorded before (T0) and after implementation (T1) and six months after completion of the project (T2). Results: Before the implementation (T0) the use of the Bernese Pain Scale was regulated by an internal guideline but its application could not be verified during the baseline period (fulfillment rate of 0 %). After implementation (T1) at least one assessment per shift per neonate could be achieved in 99.1 % of the cases. Nurses conducted 210 assessments on 38 neonates in T1. In follow-up (T2) six months after implementation fulfillment rate of 100 % in 34 neonates was achieved with 188 pain assessments. Conclusions: This implementation strategy was successful in establishing the assessment instrument in clinical practice.

A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants

Pain is a major problem in sick newborn infants, especially for those needing intensive care. Pharmacological pain relief is the most commonly used, but might be ineffective and has side effects, including long-term neurodevelopmental sequelae. The effectiveness and safety of alternative analgesic methods are ambiguous. The objective was to review the effectiveness and safety of non-pharmacological methods of pain relief in newborn infants and to identify those that are the most effective. PubMed and Google Scholar were searched using the terms: “infant”, “premature”, “pain”, “acupuncture”, “skin-to-skin contact”, “sucrose”, “massage”, “musical therapy” and ‘breastfeeding’. We included 24 studies assessing different methods of non-pharmacological analgesic techniques. Most resulted in some degree of analgesia but many were ineffective and some were even detrimental. Sucrose, for example, was often ineffective but was more effective than music therapy, massage, breast milk (for extremely premature infants) or non-invasive electrical stimulation acupuncture. There were also conflicting results for acupuncture, skin-to-skin care and musical therapy. Most non-pharmacological methods of analgesia provide a modicum of relief for preterm infants, but none are completely effective and there is no clearly superior method. Study is also required to assess potential long-term consequences of any of these methods.

Drug metabolism in early infancy: opioids as an illustration

INTRODUCTION

Drug dosing in infants frequently depends on body weight as a crude indicator for maturation. Fentanyl (metabolized by Cytochrome P450 3A4) and morphine (glucuronidated by UDP-glucuronosyltransferase-2B7) served as model drugs to provide insight in maturation patterns of these enzymes and provide understanding of the impact of non-maturational factors to optimize dosing in infants. Areas covered: Systematic searches on metabolism and population pharmacokinetic (Pop-PK) models for fentanyl and morphine were performed. Pre- and post-model selection criteria were applied to assess and evaluate the validity of these models. It was observed that maturational changes have been rather well investigated, be it with variability in the maturational function estimates. The same holds true for Pop-PK models, where non-maturational covariates have also been reported (pharmacogenetics, disease state or external influences), although less incorporated in the PK models and with limited knowledge on mechanisms involved. Expert opinion: PK models for fentanyl and morphine are currently available. Consequently, we suggest that researchers should not continue to develop new models, but should investigate whether collected data fit in already existing models and provide additional value concerning the impact of (non)-maturational factors like drug-drug interactions or pharmacogenetics.

The respiratory physiotherapy causes pain in newborns? A systematic review

Abstract Introduction: Neonatal respiratory physicaltherapy plays an important role in prevention and treatment of respiratory pathologies. In preterm neonates, immaturity of respiratory system can let development of various respiratory diseases. Meanwhile, it is discussed if respiratory physiotherapy can cause pain. Objective: Investigate presence of pain in neonates undergone to respiratory physiotherapy by a systematic review. Methods: Scientific search in electronic databases: Medline, Lilacs, Bireme, PEDro, Pubmed, Scielo and Capes thesis and dissertations base. Portuguese, English and Spanish, publication year from 2000 to 2012. Results: Thriteen studies were included, but one of them was excluded due to fulltext unavaiable. Therefore, twelve articles were included, nine (81,8%) confirm pain in newborn (NB), from these, in eight (72,7%) intervention was suction and in only one vibrocompression. Four articles studied term and premature newborns. Mechanical ventilatory assistance was used in seven of the studies analyzed. Conclusion: Results suggest that suction and vibrocompression were pain causers in NB. However, evidenced the necessity of well delineated methods to evaluate if physicaltherapy techniques can cause pain in neonates.

The Validity and Clinical Utility of the COVERS Scale and Pain Assessment Tool for Assessing Pain in Neonates Admitted to an Intensive Care Unit

OBJECTIVES

Infants admitted to a neonatal intensive care unit (NICU) are routinely subject to a range of painful procedures. However, pain assessments in NICUs are under-utilized due to a lack of a gold standard pain measure. In this study we assessed the psychometric properties and clinical utility of the COVERS and Pain Assessment Tool (PAT), in a neonatal unit.

METHODS

We had 72 nurses use the scales to assess pain at baseline and during a heel-lance procedure in 80 NICU infants. An independent research observer and the infant's mother also completed pain ratings. After the study, we assessed nurse preference and clinical utility ratings for both scales.

RESULTS

The COVERS had satisfactory internal consistency at baseline (Cronbach α=0.74) and heel lance (α=0.78), as did the PAT (baseline α=0.79, heel lance α=0.85). Intraclass correlation coefficients demonstrated good inter-rater reliability at baseline and heel lance, respectively, for both the COVERS (0.82 and 0.80) and the PAT (0.83 and 0.86). There were strong associations between total scores on the 2 scales at baseline (r=0.81, P<0.001) and heel lance (r=0.91, P<0.001), between researcher's ratings and total COVERS (ρ=0.75, P<0.001) and PAT scores (ρ=0.69, P<0.001), and between maternal ratings and total COVERS (r=0.74, P<0.05) and PAT scores (r=0.65, P<0.05). Both scales were sensitive to pain and nonpain events. Reliability and validity was mostly upheld across gestational age. Most nurses preferred the COVERS (52%) to the PAT (16%), and 32% had no preference.

DISCUSSION

This study builds on evidence for the COVERS scale and the PAT; both scales were reliable and valid measures of acute pain in neonates as premature as 24-week gestational age.

Treatment of Pain in Pediatric Patients

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period?

OBJECTIVE

To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011.

METHODS

This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3cm).

RESULTS

For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries.

CONCLUSIONS

Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

Pain management in neonates

Multiple lines of evidence suggest an increased sensitivity to pain in neonates. Repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Despite impressive gains in the knowledge of neonatal pain mechanisms and strategies to treat neonatal pain acquired during the last 15 years, a large gap still exists between routine clinical practice and research results. Accurate assessment of pain is crucial for effective pain management in neonates. Neonatal pain management should rely on current scientific evidence more than the attitudes and beliefs of care-givers. Parents should be informed of pain relief strategies and their participation in the health care plan to alleviate pain should be encouraged. The need for systemic analgesia for both moderate and severe pain, in conjunction with behavioral/environmental approaches to pain management, is emphasized. A main sources of pain in the neonate is procedural pain which should always be prevented and treated. Nonpharmacological approaches constitute important treatment options for managing procedural pain. Nonpharmacological interventions (environmental and preventive measures, non-nutritive sucking, sweet solutions, skin-skin contact, and breastfeeding analgesia) can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed, and directly, by blocking nociceptive transduction or transmission or by activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. Opioids are the mainstay of pharmacological pain treatment but there are other useful medications and techniques that may be used for pain relief. National guidelines are necessary to improve neonatal pain management at the institutional level, individual neonatal intensive care units need to develop specific practice guidelines regarding pain treatment to ensure that all staff are familiar with the effects of the drugs being used and to guarantee access and safe administration of pain treatment to all neonates.

Breastfeeding or breast milk for procedural pain in neonates

BACKGROUND

Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in situations where the neonate is 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 this purpose.

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 performed a literature search using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 10), MEDLINE (1966 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), abstracts from the annual meetings of the Society for Pediatric Research (1994 to 2011), and major paediatric pain conference proceedings. We did not apply any language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic 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 risk ratio (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.

MAIN RESULTS

Of twenty eligible studies, ten evaluated breastfeeding and ten evaluated supplemental breast milk. Sixteen studies analysed used heel lance and four used venepuncture as procedure. We noted marked heterogeneity in control intervention and pain assessment measures among the studies. Neonates in the breastfeeding group had statistically a significantly lower increase in heart rate, reduced proportion of crying time and reduced duration of first cry and total crying time compared to positioning (swaddled and placed in a crib), holding by mother, placebo, pacifier use, no intervention or oral sucrose group, or both.Premature Infant Pain Profile (PIPP) scores were significantly lower in the breastfeeding group compared to positioning, placebo or oral sucrose group, or both. However, there was no statistically significant difference in PIPP scores when compared to no intervention. Douleur Aigue Nouveau-ne scores (DAN) were significantly lower in the breastfeeding group compared to the placebo group and the group held in mother's arms, but not when compared to the glucose group. Neonatal Infant Pain Scale (NIPS) was significantly lower in the breastfeeding group compared to the no intervention group, but there was no difference when compared to the oral sucrose group. The Neonatal Facial Coding System (NFCS) was significantly lower in the breastfeeding group when compared to oral glucose, pacifier use, holding by mother and no intervention, but no difference was found when compared to formula feeding.Supplemental breast milk yielded variable results. Neonates in the supplemental breast milk group had a significantly lower increase in heart rate, a reduction in duration of crying and a lower NFCS compared to the placebo group. Neonates in the supplemental breast milk group had a significantly higher increase in heart rate changes when compared to the sucrose group. Sucrose (in any concentration, i.e. 12.5%, 20%, 25%) was found to reduce the duration of cry when compared to breast milk, as did glycine, pacifier use, rocking, or no intervention. Breast milk was found not to be effective in reducing validated and non-validated pain scores such as NIPS, NFCS, and DAN; only being significantly better when compared to placebo (water) or massage. We did not identify any study that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.

AUTHORS' CONCLUSIONS

If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.

The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates

BACKGROUND

Neonates in a neonatal intensive care unit are exposed to a high number of painful procedures. Since repeated and sustained pain can have consequences for the neurological and behaviour-oriented development of the newborn, the greatest attention needs to be paid to systematic pain management in neonatology. Non-pharmacological treatment methods are being increasingly discussed with regard to pain prevention and relief either alone or in combination with pharmacological treatment.

AIMS

To identify effective non-pharmacological interventions with regard to procedural pain in neonates.

METHODS

A literature search was conducted via the MedLine, CINAHL, Cochrane Library databases and complemented by a handsearch. The literature search covered the period from 1984 to 2004. Data were extracted according to pre-defined criteria by two independent reviewers and methodological quality was assessed.

RESULTS

13 randomised controlled studies and two meta-analyses were taken into consideration with regard to the question of current nursing practice of non-pharmacological pain management methods. The selected interventions were "non-nutritive sucking", "music", "swaddling", "positioning", "olfactory and multisensorial stimulation", "kangaroo care" and "maternal touch". There is evidence that the methods of "non-nutritive sucking", "swaddling" and "facilitated tucking" do have a pain-alleviating effect on neonates.

CONCLUSIONS

Some of the non-pharmacological interventions have an evident favourable effect on pulse rate, respiration and oxygen saturation, on the reduction of motor activity, and on the excitation states after invasive measures. However, unambiguous evidence of this still remains to be presented. Further research should emphasise the use of validated pain assessment instruments for the evaluation of the pain-alleviating effect of non-pharmacological interventions.

Does topical amethocaine gel reduce pain from heel prick blood sampling in premature infants? A randomized double-blind cross-over controlled study

BACKGROUND

Heel prick blood sampling is the most common painful invasive procedure performed on neonates. Currently, there are no effective ways to provide pain relief from this painful procedure.

OBJECTIVE

To assess the efficacy of the topical anesthetic amethocaine 4% gel (Ametop, Smith & Nephew Inc, St Laurent) in reducing the pain of heel prick blood sampling in neonates.

METHODS

A randomized, double-blind, placebo controlled, crossover trial was conducted. Neonates between 33 to 37 weeks' gestational age in their first seven days of life were eligible. Heel prick blood sampling was performed on each participant twice. Each infant was randomly assigned to receive either amethocaine 4% gel or placebo to the heel for the first prick, and then received the alternative agent for the second prick. Prick pain was assessed using both Premature Infant Pain Profile (PIPP) and Neonatal Infant Pain Scale (NIPS). Squeeze pain was assessed by NIPS.

RESULTS

Ten babies were recruited. There were no significant differences in the average PIPP and NIPS scores between the treatment and placebo groups for both prick and squeeze pains from heel prick blood sampling. For prick pain, linear-regression showed significant correlation between the PIPP and NIPS scores. No adverse reactions were observed after application of either the active or placebo agents.

CONCLUSION

Topical amethocaine 4% gel is not shown to reduce prick and squeeze pains significantly from heel prick blood sampling in neonates between 33 to 37 weeks' gestational age. Further studies are needed to find ways to provide effective pain relief from this common procedure.

Assessment of acute pain in children: development of evidence-based guidelines

AIM

Detecting children's pain in a healthcare setting can be improved by facilitating pain expression in ways that are appropriate to the child's cognitive development and that can be recognised by their carers. To ensure up-to-date guidance on assessing pain in children, the Royal College of Nursing undertook an evidence-based update of pain assessment guidelines, initially published in 2000.

METHODS

Following systematic review of the psychometric testing literature, a two-stage critical appraisal process was developed to derive a list of robust tools that could be recommended for use in a variety of settings to assess the intensity of a child's acute pain. Studies were appraised on the basis of their relevance to this topic and according to prespecified quality criteria. Tools were assessed for inclusion in guideline recommendations according to minimum validity and reliability thresholds.

RESULTS

Overall the quality of literature was poor, limited by small samples, lack of control groups, unblinded raters and convenience sampling. Twenty-four tools are recommended for use with infants and verbal children without cognitive impairment, 11 of which are purely self-report tools. Eight tools are recommended for use with neonates, some of which require concurrent physiological measures. Four tools are considered valid for use in children with cognitive impairment. All of these tools had shown reliability and validity according to the criteria established for this review.

CONCLUSION

The tools are presented in user-friendly tables that include a guide to their key features and the setting and age groups in which they have been validated. They are accompanied by good practice recommendations from experts and recommendations relating to timing and triggers for pain assessment. These outputs are some of those associated with the full guidelines and supporting material published on the Royal College of Nursing website (http://www.rcn.org.uk/childrenspainguideline).

A vibração torácica na fisioterapia respiratória de recém-nascidos causa dor?

OBJETIVO: Avaliar a dor em recém-nascidos pré-termo (RNPT) submetidos à fisioterapia respiratória em Unidade de Terapia Intensiva Neonatal. MÉTODOS: Estudo transversal realizado com recém-nascidos prematuros, com indicação de fisioterapia respiratória, em respiração espontânea. Foi aplicada uma técnica de vibração torácica com a mão do terapeuta realizando pequenas oscilações sobre o tórax do paciente e feita a avaliação da frequência cardíaca (FC), frequência respiratória (FR), saturação de pulso de oxigênio (SpO2) e do Sistema de Codificação da Atividade Facial Neonatal (NFCS) para a avaliação da dor antes, durante, imediatamente após (pós-i) e 30 minutos após (pós-30) a vibração no tórax do paciente. Utilizou-se a análise de variância para medidas repetidas para comparação entre as fases, considerando-se significante p<0,05. RESULTADOS: Foram avaliados 13 RNPT, com média de idade gestacional 32,5±2,0 semanas e peso de nascimento 1830±442g. Não foi observada pontuação de dor durante toda a avaliação: pré: 0,5±1,7; durante: 1,5±1,4; pós-i: 1,0±1,3; pós-30: 0±0,3, porém houve diferença estatisticamente significativa entre a fase pós-i e pós-30 na escala NFCS (p<0,05). A FC variou de 120 a 150bpm, a SpO2 permaneceu acima de 95%, e a FR entre 40 e 62rpm, sem diferenças entre os períodos. CONCLUSÕES: Neste grupo de pacientes prematuros internados em UTI neonatal e submetidos à realização de fisioterapia respiratória pela técnica de vibração torácica, não foram observadas alterações fisiológicas e comportamentais de dor

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Changes in physiological and behavioural pain indicators over time in preterm and term infants at risk for neurologic impairment

BACKGROUND

Approximately 10% of infants admitted to a Neonatal Intensive Care Unit (NICU) are at risk for Neurological Impairment (NI). While we have limited knowledge on the influence of NI risk on pain responses, we have no knowledge of how these responses change over time.

OBJECTIVE

To compare physiological and behavioural pain responses of infants at three levels of NI risk during the NICU neonatal period (Session 1) and at 6 months of age (Session 2).

DESIGN/METHODS

Prospective observational design with 149 preterm and term infants at high (Cohort A, n=54), moderate (Cohort B, n=45) and mild (Cohort C, n=50) risks for NI from 3 Canadian tertiary level NICUs. Infants were observed in the NICU during 3 standardized phases of a heel lance: baseline, stick and return-to-baseline. At 6 months, infants were observed during the same three phases during an intramuscular immunization injection. Physiological (heart rate, oxygen saturation) and behavioural (9 facial actions, cry) responses were continuously recorded.

RESULTS

A significant interaction of Phase by Session was found with less total facial activity observed during Session 2 (all p values<0.04). A significant interaction for Session by Cohort was found, showing that infants in Cohort A had significantly more change from baseline-to-stick phase for brow bulge, eye squeeze, nasolabial furrow and open lips between sessions with less facial actions demonstrated at Session 2 (all p<0.02). There were significantly lower mean and minimum heart rate (all p<0.02) and higher minimum and maximum oxygen saturation (p<0.04) at Session 2. Significantly higher mean and minimum fundamental cry frequencies (pitch) in Cohort B (p<0.04) were found in Session 1. Cohort A had significantly longer cry durations, but no significant differences in cry dysphonation.

CONCLUSIONS

Behavioural and physiological infant pain responses were generally diminished at 6 months of age compared to those in the neonatal period with some differences between NI risk groups in cry responses. Future exploration into the explanation for these differences between sessions and cohorts is warranted.

Opioids for neonates receiving mechanical ventilation

BACKGROUND

Mechanical ventilation is a potentially painful and discomforting intervention widely used in neonatal intensive care units. Newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation.

SEARCH STRATEGY

Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007); MEDLINE (1966 to June 2007); EMBASE (1974 to June 2007); and CINAHL (1982 to 2007). Previous reviews and lists of relevant articles were cross-referenced.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, in which case a random effects model was used.

MAIN RESULTS

Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

Inter-observer reliability of two pain scales for newborns

AIM

To assess inter-observer reliability of two of the most widely used pain scales for newborns.

BACKGROUND

More than 30 scales exist to assess neonatal pain, but they are rarely used because they are too complicated or unreliable.

METHOD

We scored pain level in two groups of babies during a heelprick. The first group of 20 premature babies (mean gestational age: 34.2+/-1.2 weeks) was studied using the PIPP scale, and the second group of 20 term babies (mean gestational age: 39.5+/-0.9 weeks) with the NIPS scale. We compared the pain scores assigned by the nurse who took the blood sample (nurse A) and those assigned by another who was present during heelprick (nurse B) with those assigned by a nurse who later watched the video clip of the procedure (nurse C). We chose the latter as "objective" score, because in this case the scorer could watch the recorded event several times, timing and scoring it thoroughly.

FINDING

NIPS: 8/20 scores were different between nurse A and nurse C, but only in one case was this difference greater than 2 (Cohen's K=0.60). In the case of nurse B, there were 12/20 differences with respect to the score assigned by nurse C but only one baby was assigned a score that differed by more than 2 (Cohen's K=0.30). PIPP: 16/20 scores were different between nurse A and nurse C; in 9 cases this difference was more than 2 (Cohen's K=0.10). In the case of nurse B, differences with respect to the score assigned by nurse C occurred in 17/20 cases and for six babies the difference in score was more than 2 (Cohen's K=0.16).

CONCLUSION

Our results indicate a higher inter-observer reliability of NIPS than PIPP, though NIPS did not have a very high inter-observer agreement score. Caregivers who use them to assess pain in real time at the cribside should be aware of the limits we have highlighted in this study.

Is the ABC pain scale reliable for premature babies?

AIM

We recently developed the ABC scale to assess pain in term newborns. The aim of the present study was to assess the reliability of the scale in preterm babies.

MATERIAL AND METHODS

The scale consists of three cry parameters: (a) pitch of the first cry, (b) rhythmicity of the bout of crying and (c) cry constancy. Changes in these parameters were previously found to distinguish medium and high levels of pain as evaluated by spectral analysis of crying. We enrolled 72 babies to perform the steps usually requested to validate a scale, namely the study of the concurrent validity, specificity and sensibility. Moreover, we assessed the interjudge reliability and the clinical utility and ease of the scale.

RESULTS

A good correlation (r = 0.68; r(2)= 0.45; p < 0.0001) was found between scores obtained with the ABC scale and the premature infant pain profile (PIPP) scale, demonstrating a good concurrent validity. The scale also showed good sensitivity and specificity (we found statistically significant differences between mean values of scores obtained in babies who underwent pain and babies who underwent non-painful stimulus.) Interobserver reliability was good: Cohen's kappa = 0.7.

CONCLUSION

The good correlation between the two scales shows that the ABC scale is also reliable for premature babies.

Breastfeeding or breastmilk to alleviate procedural pain in neonates: a systematic review

OBJECTIVES

To (1) compare breastfeeding with control (placebo, no treatment, sucrose, glucose, pacifiers, or positioning) and (2) compare breastmilk with control for procedural pain in neonates.

METHODS

Systematic review and meta-analyses of randomized and quasi-randomized trials of breastfeeding or supplemental breastmilk for procedural pain in neonates was carried out on studies identified from electronic databases and hand searches without language restrictions. The methodological quality of the trials was assessed according to the Neonatal Review Group of Cochrane Collaboration.

RESULTS

Eleven eligible studies were identified. Marked heterogeneity in control intervention and pain assessment measures was noted. The breastfeeding group had significantly less increase in the heart rate, reduced proportion of crying time and reduced duration of crying compared to the swaddled or pacifier group. Premature Infant Pain Profile scores were lower in the breastfeeding group when compared to the placebo and the group positioned in mother's arms, but were not different compared to the no-treatment and the glucose groups. Neonates in the supplemental breastmilk group had a significantly less increase in the heart rate and Neonatal Facial Coding Score but no significant difference in the duration of crying time and oxygen saturation change compared to the placebo.

CONCLUSIONS

If available, breastfeeding or breastmilk should be used to alleviate pain in neonates undergoing painful procedure compared to placebo, positioning, or no intervention. Administration of glucose/sucrose had a similar effectiveness as breastfeeding for reducing pain. The effectiveness of breastmilk for repeated painful procedures is not established, and further research is needed.

Development and preliminary psychometric testing of the Multidimensional Assessment of Pain Scale: MAPS

BACKGROUND

This study aimed to test the preliminary psychometric properties of the Multidimensional Assessment Pain Scale (MAPS), a clinical instrument developed for assessing postoperative pain in critically ill preverbal children.

METHODS

The MAPS was developed using pain indicators observed in postoperative critically ill infants. Content validity was established by a panel of experts. The scale was tested for validity and reliability in 43 postoperative children aged 0-31 months admitted to the pediatric intensive care units of two tertiary referral hospitals. Pain was measured concurrently by three independent assessors using the MAPS, the Face, Leg, Activity, Cry, and Consolability scale (FLACC) and the Visual Analog Scale (VAS) to assess concurrent and convergent validity.

RESULTS

Internal consistency was moderate (r = 0.68). Interrater reliability of the MAPS was good (kappa: 0.68-0.84) for all categories and moderate for breathing pattern (kappa = 0.54). Excellent interrater reliability was shown for total MAPS (intraclass correlation 0.91). Agreement measurements between MAPS and FLACC, and MAPS and VAS showed that the risk of measurement error was small.

CONCLUSION

Although initial psychometric testing of the MAPS shows promising results, the tool requires further psychometric testing, including responsiveness to analgesic effect (currently in progress).

Psychometric testing of a Norwegian version of the Premature Infant Pain Profile: an acute pain assessment tool. A clinical validation study

As neonates are submitted to pain, assessing the pain is crucial in effective pain control. The Premature Infant Pain Profile, an acute measurement tool combining physiological, behavioural and contextual indicators, was translated into Norwegian and tested clinically. The purpose was to establish construct validity, interrater reliability and internal consistency. In addition, the effect of sucrose as pain analgesia was tested in neonates >or= 36 weeks of gestational age. In a known-groups comparisons design with repeated measures, 111 consecutive neonates, preterm and term, were all observed at baseline, non-pain and pain event. Neonates in the neonatal unit received sucrose at pain event. A significant interaction effect of gestational age and events was found in the sucrose neonates. A significant interaction effect was detected from sucrose and event type for neonates from 36 weeks. The internal consistency of the six-item score was acceptable. A correlation coefficient of 0.89-0.97 was obtained for interrater reliability. The Norwegian version of the Premature Infant Pain Profile seems to be a reliable and valid instrument for pain assessment in neonates.

Multidimensional pain assessment of preterm newborns at the 1st, 3rd and 7th days of life

CONTEXT AND OBJECTIVE

It is challenge to assess and treat pain in premature infants. The objective of this study was to compare the multidimensional pain assessment of preterm neonates subjected to an acute pain stimulus at 24 hours, 72 hours and seven days of life.

DESIGN AND SETTING

Prospective cohort study, at Universidade Federal de São Paulo.

METHODS

Eleven neonates with gestational age less than 37 weeks that needed venepuncture for blood collection were studied. The exclusion criteria were Apgar score < 7 at five minutes, presence of any central nervous system abnormality, and discharge or death before seven days of life. Venepuncture was performed in the dorsum of the hand, and the heart rate, oxygen saturation and pain scales [Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), and Premature Infant Pain Profile (PIPP)] were assessed at 24 hours, 72 hours and 7 days of life. NFCS and NIPS were evaluated prior to procedure (Tpre), during venepuncture (T0), and two (T2) and five (T5) minutes after needle withdrawal. Heart rate, O2 saturation and PIPP were measured at Tpre and T0. Mean values were compared by repeated-measurement analysis of variance.

RESULTS

The pain parameters did not differ at 24 hours, 72 hours and 7 days of life: heart rate (p = 0.22), oxygen saturation (p = 0.69), NFCS (p = 0.40), NIPS (p = 0.32) and PIPP (p = 0.56).

CONCLUSION

Homogeneous pain scores were observed following venepuncture in premature infants during their first week of life.

Determining behavioural and physiological responses to pain in infants at risk for neurological impairment

Multiple researchers have validated indicators and measures of infant pain. However, infants at risk for neurologic impairment (NI) have been under studied. Therefore, whether their pain responses are similar to those of other infants is unknown. Pain responses to heel lance from 149 neonates (GA>25-40 weeks) from 3 Canadian Neonatal Intensive Care units at high (Cohort A, n=54), moderate (Cohort B, n=45) and low (Cohort C, n=50) risk for NI were compared in a prospective observational cohort study. A significant Cohort by Phase interaction for total facial action (F(6,409)=3.50, p=0.0022) and 4 individual facial actions existed; with Cohort C demonstrating the most facial action. A significant Phase effect existed for increased maximum Heart Rate (F(3,431)=58.1, p=0.001), minimum Heart Rate (F(3,431)=78.7, p=0.001), maximum Oxygen saturation (F(3,425)=47.6, p=0.001), and minimum oxygen saturation (F(3,425)=12.2, p=0.001) with no Cohort differences. Cohort B had significantly higher minimum (F(2,79)=3.71, p=0.029), and mean (F(2,79)=4.04, p=0.021) fundamental cry frequencies. A significant Phase effect for low/high frequency Heart Rate Variability (HRV) ratio (F(2,216)=4.97, p=0.008) was found with the greatest decrease in Cohort A. Significant Cohort by Phase interactions existed for low and high frequency HRV. All infants responded to the most painful phase of the heel lance; however, infants at moderate and highest risk for NI exhibited decreased responses in some indicators.

Neonatal pain analyzer: development and validation

We developed a pain analyzer (ABC analyzer) to perform automatic acoustic analysis of neonatal crying and to provide an objective estimate of neonatal pain. The ABC analyzer uses a validated pain scale (ABC scale) based on three acoustic parameters: pitch frequency, normalized RMS amplitude, and presence of a characteristic frequency- and amplitude-modulated crying feature, defined as "siren cry". Here we assessed the reliability of the analyzer. We enrolled 57 healthy neonates. Each baby was recorded with a video camera during heel prick. Pain intensity was evaluated using a validated scale [Douleur Aigue du Nouveau-Né (DAN) scale] and the analyzer and the two scores were compared. We found a statistically significant concordance between the DAN score and ABC analyzer score (p < 0.0001). The ABC analyser is a novel approach to cry analysis that should now have its properties carefully evaluated in a series of studies, just as is necessary in the development of any other pain measurement tool.

Breastfeeding or breast milk for procedural pain in neonates

BACKGROUND

Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in the changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in situations where the neonate is experiencing pain or stress. Nonpharmacological measures (such as holding, swaddling, breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for this purpose.

OBJECTIVES

The primary objective of this review 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, type of painful procedure, gestational age and the amount of supplemental breast milk given.

SEARCH STRATEGY

A literature search was performed using MEDLINE (1966 - Feb 2006), EMBASE (1980 - Feb 2006), CINAHL (1982 - Feb 2006), Cochrane Central Register of Controlled Trials (Issue 4, 2005 of Cochrane Library), abstracts from the annual meetings of the Society for Pediatric Research (1994 - 2006) and major pediatric pain conference proceedings. No language restrictions were applied.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic markers of pain or validated pain scores.

DATA COLLECTION AND ANALYSIS

The methodological quality of the trials was assessed using the information provided in the studies and by personal communication with the authors. Data on relevant outcomes were extracted and the effect size was estimated and reported as relative risk (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.

MAIN RESULTS

Eleven eligible studies were identified. Marked heterogeneity in terms of control intervention and pain assessment measures were noted among the studies. Neonates in the breastfeeding group had statistically significantly less increase in the heart rate, reduced proportion of crying time and reduced duration of crying compared to swaddled group or pacifier group. Neonates in the breastfeeding group had a significant reduction in duration of crying compared to fasting (no intervention) group, but there was no significant difference when compared to glucose group. Premature Infant Pain Profile scores were significantly different between the breastfeeding group when compared to placebo group and the group positioned in mother's arms. However, these scores were not statistically significantly different in the breastfeeding group when compared to the no treatment group and the glucose group. Douleur Aigue Nouveau-ne scores were significantly different in the breastfeeding group when compared to the placebo group and the group positioned in mother's arms, but not when compared to the glucose group. Neonates in the supplemental breast milk group had significantly less increase in the heart rate and Neonatal Facial Coding Score compared to the placebo group. The differences in the duration of crying time and oxygen saturation change between supplemental breast milk group and the placebo group were not statistically significant. Neonates in the supplemental breast milk group had significantly higher increase in the heart rate changes and duration of crying time compared to glucose/sucrose group. No study was identified that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.

AUTHORS' CONCLUSIONS

If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure compared to placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for repeated painful procedures is not established and further research is needed. These studies should include various control interventions including glucose/ sucrose and should target preterm neonates.

Capturing postoperative pain responses in critically ill infants aged 0 to 9 months

OBJECTIVES

The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time.

DESIGN

This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist.

PATIENTS

A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery.

MEASUREMENTS AND MAIN RESULTS

There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli.

CONCLUSIONS

Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool for this group of infants.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome?

BACKGROUND/PURPOSE

Continuous epidural analgesia is routinely used to manage pain in infants undergoing resection of a congenital cystic adenomatoid malformation (CCAM) of the lung. Our aim was to determine if there is a difference in the length of stay (LOS), supplemental analgesic requirements, pain control, and the incidence of adverse respiratory events in infants receiving the 2 standard epidural solutions commonly used: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 microg/mL.

METHODS

We retrospectively reviewed the charts of infants who received epidural infusions containing bupivacaine 0.1% (n = 18) and bupivacaine 0.1% with fentanyl 2 to 5 microg/mL (n = 10) after CCAM resection during a 12-month period. LOS, rescue opioid, and nonopioid analgesic use, incidence of respiratory depression, and pain scores were recorded.

RESULTS

The LOS in patients receiving fentanyl in their epidural solution was 1 day longer than those receiving plain bupivacaine (median 4 vs 3 days, respectively). Nonopioid analgesic and rescue opioid use was greater in patients who did not have fentanyl in their epidural solutions. Pain ratings were not significantly different. The incidence of respiratory depression was greater in patients receiving epidural infusions containing fentanyl (50% vs 17%, respectively).

CONCLUSION

The addition of fentanyl to epidural infusions of bupivacaine in infants undergoing thoracotomy for resection of CCAM may prolong recovery and increase the incidence of adverse respiratory events without providing a significant analgesic benefit.

Opioids for neonates receiving mechanical ventilation

BACKGROUND

Mechanical ventilation is a potentially painful intervention widely used in neonatal intensive care units. Since newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes, the use of drugs which reduce pain might be very important.

OBJECTIVES

To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation.

SEARCH STRATEGY

Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004); MEDLINE (1966 to June 2004); EMBASE (1974 to June 2004); and CINAHL (1982 to 2003). Previous reviews and lists of relevant articles were cross-referenced.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, when a random effects model was used.

MAIN RESULTS

Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

Postoperative pain assessment in the neonatal intensive care unit

OBJECTIVES

To compare the convergent validity of two measures of pain (premature infant pain profile (PIPP) and crying, requires oxygen, increased vital signs, expression, and sleepless (CRIES)) in real life postoperative pain assessment in infants.

METHODS

This study was a prospective, repeated measures, correlational design. Two staff nurses were randomly assigned either the PIPP or CRIES measure. An expert rater assessed each infant after surgery, and once a day using the visual analogue scale (VAS).

SETTING

A level III neonatal intensive care unit in a metropolitan university affiliated paediatric hospital.

RESULTS

Pain was assessed in 51 neonates (28-42 weeks of gestational age) after surgery. There was no significant difference in the rates of change between the pain assessment measures across time using repeated measures analysis of variance (F(50,2) = 0.62, p = 0.540), indicating correlation between the measures. Convergent validity analysis using intraclass correlation showed correlation, most evident in the first 24 hours (immediately, 4, 8, 20, and 24 hours after the operation). Correlations were more divergent at 40 and 72 hours after surgery. No significant interactions were found between gestational age and measure (F(304,4) = 0.75, p = 0.563) and surgical group and measure (F(304,2) = 0.39, p = 0.680).

CONCLUSIONS

PIPP and CRIES are valid measures that correlate with pain for the first 72 hours after surgery in term and preterm infants. Both measures would provide healthcare professionals with an objective measure of a neonatal patient's pain.

Pain relief for neonatal circumcision

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWERS' CONCLUSIONS

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

Pain assessment in the neonate using the Bernese Pain Scale for Neonates

BACKGROUND

Neonates who require treatment in the neonatal intensive care unit (NICU) are subjected to many invasive painful procedures.

AIMS

Assessment of pain in preterm and term neonates with or without ventilation on continuous positive airway pressure using the Bernese Pain-Scale for Neonates (BPSN). The validity and the reliability of the BPSN was established.

STUDY DESIGN AND SUBJECTS

Pain assessments (n=288) were performed by 6 health care workers in different situations of term and preterm neonates. Each neonate (n=12) was observed in four given situations (after feeding, while a foot was being warmed, while a routine capillary blood sample was taken and 15 min after the blood sample was taken). Pain assessments were made by two nurses at the bedside using the BPSN, the Visual-Analogue Scale (VAS) and the Premature Infant Pain Profile (PIPP). At the same time, a video sequence was made which was shown later to four different nurses to assess pain using the BPSN, the PIPP, and the VAS.

RESULTS

The construct validity of the BPSN was very good (F=41.3, p<0.0001). Moreover, concurrent and convergent validity of the BPSN compared to VAS and PIPP was r=0.86, and r=0.91, p<0.0001, respectively. Finally, the study demonstrated high coefficients for interrater (r=0.86-0.97) and intrarater reliability (r=0.98-0.99).

CONCLUSION

The BPSN was shown to be a valid and reliable tool for assessing pain in term and preterm neonates with and without ventilation.

A systematic integrative review of infant pain assessment tools

PURPOSE

To examine the issue of pain assessment in infants by acquiring all available published pain assessment tools and evaluating their reported reliability, validity, clinical utility, and feasibility.

DESIGN AND METHODS

A systematic integrative review of the literature was conducted using the following databases: MEDLINE and CINAHL (through February 2004), and Health and Psychosocial Instruments, and Cochrane Systematic Reviews (through 2003). MeSH headings searched included "pain measurement," with limit of "newborn infant"; "infant newborn"; and "pain perception."

SUBJECTS

Thirty-five neonatal pain assessment tools were found and evaluated using predetermined criteria. The critique consisted of a structured comparison of the classification and dimensions measured. Further, the population tested and reports of reliability, validity, clinical utility, and feasibility were reviewed.

RESULTS

Of the 35 measures reviewed, 18 were unidimensional and 17 were multidimensional. Six of the multidimensional measures were published as abstracts only, were not published at all, or the original work could not be obtained. None of the existing instruments fulfilled all criteria for an ideal measure; many require further psychometric testing.

CONCLUSIONS

When choosing a pain assessment tool, one must also consider the infant population and setting, and the type of pain experienced. The decision should be made after carefully considering the existing published options. Confidence that the instrument will assess pain in a reproducible way is essential, and must be demonstrated with validity and reliability testing. Using an untested instrument is not recommended, and should only occur within a research protocol, with appropriate ethics and parental approval. Because pain is a multidimensional phenomenon, well-tested multidimensional instruments may be preferable.

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

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

Behavioral and Physiological Indicators of Procedural and Postoperative Pain in High‐Risk Infants

Nurses play a critical role in the assessment and management of infant pain. In this article, infant pain assessment tools that are valid, reliable, clinically sensitive, and developmentally appropriate are discussed. Their purpose, use in acute pain, and applicability for premature and newborn infant populations are described. Behavioral and physiological indicators of pain, sleep-wake states, and infant development are discussed as important considerations in pain assessment. Recommendations for improving pain assessment practices are offered in conclusion.

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.

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

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

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.

Pilot study of a pain assessment tool in the Neonatal Intensive Care Unit

OBJECTIVES

To develop and validate a pain assessment tool to assess procedural pain experienced by mechanically ventilated neonates.

METHODS

Assessment of ventilated infants, before, during and after a known routine traumatic procedure using the Nepean Neonatal Intensive Care Unit Pain Assessment Tool (NNICUPAT). This tool scores physiological and behavioural responses to pain. Variables used in the NNICUPAT included facial expression, body movement, skin colour, saturation, respiratory rate, heart rate and nurses' perception of pain. To test the validity of the NNICUPAT, it was compared to a visual analogue scale (VAS), which is a unidimesional observation measure, where zero equals no pain and 10 equals severe pain.

RESULTS

Thirty ventilated neonates (mean gestation 28 +/- 3.3 standard deviation (SD)) weeks) were enrolled in the pilot study over a 9-month period. The total score before the procedure was: 0.26 +/- 0.14 (mean +/- standard error of the mean (SEM)) range 0-3; total score during the procedure 5.1 +/- 2.2 (mean +/- SD) range 1-10; and the total score after the procedure was 0.26 +/- 0.15 (mean +/- SEM) range 0-3. There was a significant correlation between the NNICUPAT and the VAS during the procedure (r = 0.825, P = < 0.01) and after the procedure (r = 0.375, P = < 0.05). Inter-rater reliability was calculated between the principle coder and other coders (using the NNICUPAT) and showed a significant correlation before (r = 0.88, P < 0.01) and during (r = 0.88, P < 0.01) the procedure.

CONCLUSIONS

The NNICUPAT does show validity in the assessment of procedural pain in the ventilated neonate. Further evaluation of both inter- and intra-rater reliability will be necessary to establish the ongoing validity of the NNICUPAT.

Nursing assessment of infant pain

This study compared how nurses perceived their assessment of infant pain and how the pain was actually assessed in an intensive care unit. A descriptive design was used to collect data about nurses beliefs and documentation practices related to pain assessment in infants. An anonymous subset of the unit nurses (n = 24) responded to a questionnaire regarding infant pain assessment. Pain assessment documentation of the unit nurses was examined in a retrospective chart review (n = 107). Results showed an inconsistency between what nurses believe about infant pain as sessment and the documentation practice in the unit. According to the questionnaire, the nurses believed that pain assessment was important to providing effective pain relief and that nurses are capable of assessing infant pain. However, it was not evident in the documentation that nurses used pain tools or other means to document their evaluations of infant pain or the infant's response to pain medication interventions.

CONCLUSION

Greater consistency of nurses in documenting pain assessment, thereby improving care provider communication of an infant's pain experience, is needed to improve the standard of care in managing infant pain.

Assessment and management of acute pain in high-risk neonates

Neonates in the neonatal intensive care unit experience hundreds of painful procedures at a time of rapid neurological development. Although the immediate responses to pain may be protective, the potential long-term effects of early and under-treated pain are concerning. As pain assessment is the first step in the provision of appropriate and timely pain management, attention should be directed to the quantification of pain in terms of its location, severity, intensity and duration. Over the past decade, numerous pain measures have been developed for preterm and term neonates, however, most of them have been developed for research purposes and have not been tested in the clinical setting. In order to effectively implement pain measures in the clinical setting, the psychometric properties of reliability, validity, feasibility and clinical utility must be established. This review paper will highlight the importance of neonatal pain assessment and examine the psychometric properties of various measures of neonatal pain. Pharmacological and non-pharmacological interventions to manage acute pain in high-risk neonates will be addressed and future research topics will be proposed.

Reliability of two behavioral tools to assess pain in preterm neonates

CONTEXT

One of the main difficulties in adequately treating the pain of neonatal patients is the scarcity of validated pain evaluation methods for this population.

OBJECTIVE

To analyze the reliability of two behavioral pain scales in neonates.

TYPE OF STUDY

Cross-sectional.

SETTING

University hospital neonatal intensive care unit.

PARTICIPANTS

22 preterm neonates were studied, with gestational age of 34 +/- 2 weeks, birth weight of 1804 +/- 584 g, 68% female, 30 +/- 12 hours of life, and 30% intubated.

PROCEDURES

Two neonatologists (A and B) observed the patients at the bedside and on video films for 10 minutes. The Neonatal Facial Coding System and the Clinical Scoring System were scored at 1, 5, and 10 minutes. The final score was the median of the three values for each observer and scale. A and B were blinded to each other. Video assessments were made three months after bedside evaluations.

MAIN MEASUREMENTS

End scores were compared between the observers using the intraclass correlation coefficient and bias analysis (paired t test and signal test).

RESULTS

For the Neonatal Facial Coding System, at the bedside and on video, A and B showed a significant correlation of scores (intraclass correlation score: 0.62), without bias between them (t test and signal test: p > 0.05). For the Clinical Scoring System bedside assessment, A and B showed correlation of scores (intraclass correlation score: 0.55), but bias was also detected between them: A scored on average two points higher than B (paired t test and signal test: p < 0.05). For the Clinical Scoring System video assessment, A and B did not show correlation of scores (intraclass correlation score: 0.25), and bias was also detected between them (paired t-test and signal test: p < 0.05).

CONCLUSION

The results strengthen the reliability of the Neonatal Facial Coding System for bedside pain assessment in preterm neonates.