Are twitches, startles, and body movements pain indicators in extremely low birth weight infants?

Co-developing sleep-wake and sensory foundations for cognition in the human fetus and newborn

In older children and adults, cognition builds upon waking sensory experience which is consolidated during sleep. In the fetus and newborn, sensory input is instead largely experienced during sleep. The nature of these sensory inputs differs within sleep, between active and quiet sleep, as well as versus wakefulness. Here, sleep-wake organisation in the fetus and newborn is reviewed, and then its interaction with sensory inputs discussed with a focus on somatosensory and auditory modalities. Next, these ideas are applied to how neurological insults affect early development, using fetal growth restriction as a test case. Finally, the argument is made that taking account of sleep-wake state during perinatal functional neuroimaging can better index sensorimotor, language, and cognitive brain activities, potentially improving its diagnostic and prognostic value. To sum up, sensory and sleep-wake functions go hand in hand during early human development. Perturbation of these twinned functions by neurological insults may mediate later neurodevelopmental deficits. Perinatal neuroimaging has the potential to track these trajectories, feasibly identifying opportunities to therapeutically intervene.

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

BACKGROUND

Pain, when treated inadequately, puts preterm infants at a greater risk of developing clinical and behavioural sequelae because of their immature pain system. Preterm infants in need of intensive care are repeatedly and persistently exposed to noxious stimuli, and this happens during a critical window of their brain development with peak rates of brain growth, exuberant synaptogenesis and the developmental regulation of specific receptor populations. Nearly two-thirds of infants born at less than 29 weeks' gestation require mechanical ventilation for some duration during the newborn period. These neonates are endotracheally intubated and require repeated endotracheal suctioning. Endotracheal suctioning is identified as one of the most frequent and most painful procedures in premature infants, causing moderate to severe pain. Even with improved nursing performance and standard procedures based on neonatal needs, endotracheal suctioning remains associated with mild pain.

OBJECTIVES

To evaluate the benefits and harms of non-pharmacological interventions for the prevention of pain during endotracheal suctioning in mechanically ventilated neonates. Non-pharmacological interventions were compared to no intervention, standard care or another non-pharmacological intervention.

SEARCH METHODS

We conducted searches in June 2023 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, Embase, CINAHL and three trial registries. We searched the reference lists of related systematic reviews, and of studies selected for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that included term and preterm neonates who were mechanically ventilated via endotracheal tube or via tracheostomy tube and required endotracheal suctioning performed by doctors, nurses, physiotherapists or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

Our main outcome measures were validated composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We used standard methodological procedures expected by Cochrane. For continuous outcome measures, we used a fixed-effect model and reported mean differences (MDs) with 95% confidence intervals (CIs). For categorical outcomes, we reported the typical risk ratio (RR) and risk difference (RD) and 95% CIs. We assessed risk of bias using the Cochrane RoB 1 tool, and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included eight RCTs (nine reports), which enroled 386 infants, in our review. Five of the eight studies were included in a meta-analysis. All studies enrolled preterm neonates. Facilitated tucking versus standard care (four studies) Facilitated tucking probably reduces Premature Infant Pain Profile (PIPP) score during endotracheal suctioning (MD -2.76, 95% CI 3.57 to 1.96; I² = 82%; 4 studies, 148 infants; moderate-certainty evidence). Facilitated tucking probably has little or no effect during endotracheal suctioning on: heart rate (MD -3.06 beats per minute (bpm), 95% CI -9.33 to 3.21; I² = 0%; 2 studies, 80 infants; low-certainty evidence); oxygen saturation (MD 0.87, 95% CI -1.33 to 3.08; I² = 0%; 2 studies, 80 infants; low-certainty evidence); or stress and defensive behaviours (SDB) (MD -1.20, 95% CI -3.47 to 1.07; 1 study, 20 infants; low-certainty evidence). Facilitated tucking may result in a slight increase in self-regulatory behaviours (SRB) during endotracheal suctioning (MD 0.90, 95% CI 0.20 to 1.60; 1 study, 20 infants; low-certainty evidence). No studies reported intraventricular haemorrhage (IVH). Familiar odour versus standard care (one study) Familiar odour during endotracheal suctioning probably has little or no effect on: PIPP score (MD -0.30, 95% CI -2.15 to 1.55; 1 study, 40 infants; low-certainty evidence); heart rate (MD -6.30 bpm, 95% CI -16.04 to 3.44; 1 study, 40 infants; low-certainty evidence); or oxygen saturation during endotracheal suctioning (MD -0.80, 95% CI -4.82 to 3.22; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH. White noise (one study) White noise during endotracheal suctioning probably has little or no effect on PIPP (MD -0.65, 95% CI -2.51 to 1.21; 1 study, 40 infants; low-certainty evidence); heart rate (MD -1.85 bpm, 95% CI -11.46 to 7.76; 1 study, 40 infants; low-certainty evidence); or oxygen saturation (MD 2.25, 95% CI -2.03 to 6.53; 1 study, 40 infants; low-certainty evidence). No studies reported SRB, SDB or IVH.

AUTHORS' CONCLUSIONS

Facilitated tucking / four-handed care / gentle human touch probably reduces PIPP score. The evidence of a single study suggests that facilitated tucking / four-handed care / gentle human touch slightly increases self-regulatory and approach behaviours during endotracheal suctioning. Based on a single study, familiar odour and white noise have little or no effect on any of the outcomes compared to no intervention. The use of expressed breast milk or oral sucrose suggests that there is no discernible advantage of one method over the other for reducing pain during endotracheal suctioning. None of the studies reported on any of the prespecified secondary outcomes of adverse events.

Pediatricians' focus of sight at pain assessment during a neonatal heel puncture

OBJECTIVE

To evaluate the focus of pediatricians' gaze during the heel prick of neonates.

METHODS

Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10).

RESULTS

24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain.

CONCLUSIONS

At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

The Neonatal Withdrawal Assessment Tool (NWAT): pilot inter-rater reliability and content validity

OBJECTIVE

There is no validated tool to assess iatrogenic opioid withdrawal in preterm infants in the newborn intensive care unit (NICU).

STUDY DESIGN

The Neonatal Withdrawal Assessment Tool (NWAT) was developed to address this gap in clinical practice. In this pilot study, the NWAT was assessed for inter-rater reliability (IRR) and content validity.

RESULT

Fifty-one NICU providers scored two standardized simulated cases, then 20 paired provider assessments were completed on 5 preterm infants. The overall IRR was 95.6% on the simulated cases, and 98.8% on the 5 pilot infants. A provider survey assessed for content validity; all of the provider participants strongly agreed/agreed that the NWAT adequately measures withdrawal in critically ill infants.

CONCLUSION

The NWAT demonstrated high IRR and content validity for assessment of iatrogenic opioid withdrawal in preterm infants in this pilot study. Further studies in a larger more diverse patient population are needed before wider adoption into clinical practice.

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

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

Pain in Preterm Infants: Different Perspectives

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

Evaluation of the Reliability and Validity of the Behavioral Indicators of Infant Pain Scale in Chinese Neonates

BACKGROUND

Behavioral Indicators of Infant Pain scale (BIIP) has been shown to be a good tool to assess pain in infants.

AIMS

This paper aimed to translate BIIP into Chinese and evaluate its reliability and validity for neonates in China.

DESIGN

A prospective observational study. SETTING AND PARTICIPANTS: A convenience sample of 396 neonates (preterm and term infants) were recruited from neonatal intensive care units in China from July to October 2016.

METHODS

The BIIP was translated and adjusted for semantic adaption.396 neonates were assessed during 3 phases of blood collection from an artery/vein. A video camera was positioned for a close-up view of the face and body. The neonates' pain was rated independently by 2 nurses who were trained and familiar with the Chinese version of BIIP (C-BIIP)and FLACC (Facial expression, Legs, Activity, Crying and Consolability).

RESULTS

The internal consistency were 0.904 (preterm) and 0.895 (term). The test-retest reliability were 0.947 (preterm) and 0.938 (term) and the interclass correlation coefficients were 0.921 to 0.959 (preterm) and 0.921 to 0.959 (term). The correlations between the C-BIIP and FLACC were high (preterm: r = 0.948, term: r = 0.896). Using the C-BIIP, the 3 phases of blood collection were found to be statistically different (preterm: F = 635.76, term: F = 675.54; P < 0.001), which showed that the construct validity of C-BIIP was good.

CONCLUSION

The BIIP is a reliable and valid tool to assess pain in term and preterm neonates in China.

Exposure and reactivity of the preterm infant to noise in the incubator

PURPOSE

To evaluate preterm infants' exposure and reactions to intense noise during incubator care.

METHODS

An observational and prospective study was performed in the intermediary care unit of a hospital in Ribeirão Preto (SP). Thirty-five preterm infants participated in the first stage of the study (measuring noise) and 20 in the second (analysis of responses to intense noise). Noise was measured for two hours using a dosimeter, and the responses were video recorded by three cameras connected to a computer. The preterm infants' responses to an Lmax higher than 65 decibels were analyzed.

RESULTS

Every preterm infant presented Leq above the limit recommended by international organizations, and more than half of the babies had a mean Leq above the limit permitted by the Brazilian standard. Regarding the babies' responses to the intense noise, the majority of them showed blink reflex, startle reflex, facial mimics, changed bodily activities or changed sleep and wake state, all with statistically significant differences.

CONCLUSION

The sound levels measured were intense. The noises that preterm infants are exposed to while being cared for in incubators constitute a stressor event. Sudden, intense noises change their behavioral state and causes reflexive and bodily responses, facial manifestations and changes in their sleep and wake state.

Applying Developmentally Supportive Principles to Diapering in the NICU: What We Know

Developmental care measures are integrated in the NICU, but these measures are largely overlooked when it comes to standard care activities such as diapering. This general review of developmental care in the NICU discusses how caregivers can apply appropriate, individualized developmental care measures to diapering regimens. Numerous opportunities to expand developmental care measures into diapering care are identified; these opportunities can protect and promote sleep for hospitalized infants, enhance the diapering environment, minimize stress that infants may experience with diapering, improve infant skin health outcomes through use of evidence-based skin care practices, and foster family involvement during diapering care in the NICU. A developmental approach to diapering offers hospitalized infants regular opportunities to reach their neurodevelopmental potential.

Defining pain in newborns: need for a uniform taxonomy?

A framework for defining pain terms such as acute, persistent, prolonged or chronic pain to newborns was derived from the scientific literature on neonatal pain assessments, previous attempts to define chronic pain and the clinical and neurophysiological features of neonatal pain. This novel framework incorporates the temporal features, localising characteristics, and secondary effects of the pain experienced, as well as the behavioural and physiological response patterns of newborns.

CONCLUSION

Although not evidence-based, this framework provides an initial starting point for defining commonly used neonatal pain terms. It will require future revision/refinement based on the accumulating evidence for non-acute pain.

The effect of positioning on preterm infants' sleep-wake states and stress behaviours during exposure to environmental stressors

Previous studies separately examined the effects of positioning or environmental stressors on preterm infants' sleep and stress. Since positioning and environmental stressors occur simultaneously during infant hospitalization exploring these variables in the same study may offer new insights. A quasi-experimental study by one-group interrupted time-series design. In the current study, a total of 22 preterm infants were enrolled. Each infant was moved to either the supine or prone position for an hour at a time. Infants were videotaped and the sleep-wake states, stress behaviours and environmental conditions (light, noise and stimulation/handling) were recorded during the observation period. A total of 80 observations from 22 infants were accrued. In the supine position, preterm infants demonstrated more frequent waking states after adjusting for various environmental stressors (p < .01). These infants demonstrated more frequent stress behaviours in the supine position after adjusting for various environmental stressors (p < .01). These results suggest that the prone position is a more favourable position for facilitating sleep and reducing stress for preterm infants exposed to varying environmental stressors. Preterm infants present different stress behaviours in response to varying types of environmental stimuli.

Neonatal pain: What's age got to do with it?

Background:

The neurobiology of neonatal pain processing, especially in preterm infants, differs significantly from older infants, children, adolescence, and adults. Research suggests that strong painful procedures or repeated mild procedures may permanently modify individual pain processing. Acute injuries at critical developmental periods are risk factors for persistent altered neurodevelopment. The purpose of this narrative review is to present the seminal and current literature describing the unique physiological aspects of neonatal pain processing.

Methods:

Articles describing the structures and physiological processes that influence neonatal pain were identified from electronic databases Medline, PubMed, and CINAHL.

Results:

The representation of neonatal pain physiology is described in three processes: Local peripheral nervous system processes, referred to as transduction; spinal cord processing, referred to as transmission and modulation; and supraspinal processing and integration or perception of pain. The consequences of undermanaged pain in preterm infants and neonates are discussed.

Conclusion:

Although the process and pain responses in neonates bear some similarity to processes and pain responses in older infants, children, adolescence, and adults; there are some pain processes and responses that are unique to neonates rendering them at risk for inadequate pain treatment. Moreover, exposure to repeated painful stimuli contributes to adverse long-term physiologic and behavioral sequelae. With the emergence of studies showing that painful experiences are capable of rewiring the adult brain, it is imperative that we treat neonatal pain effectively.

Pain in the neonate: focus on nonpharmacologic interventions

The assessment and treatment of pain in the neonate, especially preterm neonates, has been a challenge in the NICU for many years. Nurses caring for these vulnerable patients are in a key position to not only recognize when the neonate is experiencing pain but to also work collaboratively with other health care providers in determining the best method to treat and help prevent pain associated with procedures and routine caregiving activities. The American Academy of Pediatrics along with parent groups has recognized the importance of pain-prevention programs in treating pain in the neonate. Nurses, by anticipating and reducing both painful procedures and bedside interruptions, along with innovative nonpharmacologic interventions, can dramatically decrease the neonate's exposure to pain and the potential for long-term effects. An overview of nonpharmacologic interventions in the treatment of neonatal pain is provided for NICU nurses to help them effectively reduce their patient's pain and discomfort.

Neonatal pain-related stress and NFKBIA genotype are associated with altered cortisol levels in preterm boys at school age

Neonatal pain-related stress is associated with elevated salivary cortisol levels to age 18 months in children born very preterm, compared to full-term, suggesting early programming effects. Importantly, interactions between immune/inflammatory and neuroendocrine systems may underlie programming effects. We examined whether cortisol changes persist to school age, and if common genetic variants in the promoter region of the NFKBIA gene involved in regulation of immune and inflammatory responses, modify the association between early experience and later life stress as indexed by hair cortisol levels, which provide an integrated index of endogenous HPA axis activity. Cortisol was assayed in hair samples from 128 children (83 born preterm ≤32 weeks gestation and 45 born full-term) without major sensory, motor or cognitive impairments at age 7 years. We found that hair cortisol levels were lower in preterm compared to term-born children. Downregulation of the HPA axis in preterm children without major impairment, seen years after neonatal stress terminated, suggests persistent alteration of stress system programming. Importantly, the etiology was gender-specific such that in preterm boys but not girls, specifically those with the minor allele for NFKBIA rs2233409, lower hair cortisol was associated with greater neonatal pain (number of skin-breaking procedures from birth to term), independent of medical confounders. Moreover, the minor allele (CT or TT) of NFKBIA rs2233409 was associated with higher secretion of inflammatory cytokines, supporting the hypothesis that neonatal pain-related stress may act as a proinflammatory stimulus that induces long-term immune cell activation. These findings are the first evidence that a long-term association between early pain-related stress and cortisol may be mediated by a genetic variants that regulate the activity of NF-κB, suggesting possible involvement of stress/inflammatory mechanisms in HPA programming in boys born very preterm.

Neonatal pain in very preterm infants: long-term effects on brain, neurodevelopment and pain reactivity

Effects of early life psychosocial adversity have received a great deal of attention, such as maternal separation in experimental animal models and abuse/neglect in young humans. More recently, long-term effects of the physical stress of repetitive procedural pain have begun to be addressed in infants hospitalized in neonatal intensive care. Preterm infants are more sensitive to pain and stress, which cannot be distinguished in neonates. The focus of this review is clinical studies of long-term effects of repeated procedural pain-related stress in the neonatal intensive care unit (NICU) in relation to brain development, neurodevelopment, programming of stress systems, and later pain sensitivity in infants born very preterm (24-32 weeks' gestational age). Neonatal pain exposure has been quantified as the number of invasive and/or skin-breaking procedures during hospitalization in the NICU. Emerging studies provide convincing clinical evidence for an adverse impact of neonatal pain/stress in infants at a time of physiological immaturity, rapidly developing brain microstructure and networks, as well as programming of the hypothalamic-pituitary-adrenal axis. Currently it appears that early pain/stress may influence the developing brain and thereby neurodevelopment and stress-sensitive behaviors, particularly in the most immature neonates. However, there is no evidence for greater prevalence of pain syndromes compared to children and adults born healthy at full term. In addressing associations between pain/stress and outcomes, careful consideration of confounding clinical factors related to prematurity is essential. The need for pain management for humanitarian care is widely advocated. Non-pharmacological interventions to help parents reduce their infant's stress may be brain-protective.

Strategies to protect sleep

Sleep is a very important element for the development of a premature newborn, because it helps in creating good clinical condition, good weight gain, mastering full oral feeding and improving parent-infant relationship as well. Moreover, the development of a correct sleeping-awaking pattern is a key factor for the development of the brain. To protect sleep is important to modify the environment, for example, reducing noise levels, creating period of semi darkness and protecting infant face from direct light. To obtain this, individualized care, based on infant behavioural cues, becomes fundamental, requiring a change in daily assistance that should become more relationship-oriented. It is also fundamental to foster the presence of parents because it helps the baby to feel more protected and allows him to relax.

Developmental care for high-risk newborns: emerging science, clinical application, and continuity from newborn intensive care unit to community

Neonatology has optimized medical outcomes for high-risk newborns yet neurodevelopmental outcomes continue to be a concern. Basic science, clinical research, and environmental design perspectives have shown the impact of the caregiving environment on the developing brain and the role of professional caregivers in providing supportive intervention to both infants and their families. This recognition has prompted a focus on early developmentally supportive care (DSC) for high-risk newborns both in the hospital and in community follow up. DSC has emerged as a recognized standard of care in most neonatal intensive care units. Still, many questions remain and much integrative research is needed.

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).

Assessing pain in preterm infants in the neonatal intensive care unit: moving to a 'brain-oriented' approach

Preterm infants in the neonatal intensive care unit undergo repeated exposure to procedural and ongoing pain. Early and long-term changes in pain processing, stress-response systems and development may result from cumulative early pain exposure. So that appropriate treatment can be given, accurate assessment of pain is vital, but is also complex because these infants' responses may differ from those of full-term infants. A variety of uni- and multidimensional assessment tools are available; however, many have incomplete psychometric testing and may not incorporate developmentally important cues. Near-infrared spectroscopy and/or EEG techniques that measure neonatal pain responses at a cortical level offer new opportunities to validate neonatal pain assessment tools.

To explore relationships between physiological stress signals and stress behaviors in preterm infants during periods of exposure to environmental stress in the hospital

The purpose of this exploratory descriptive study was to examine relationships among physiological stress signals (heart rate (HR), respiratory rate (RR), and oxygen saturation) and stress behaviors (6 stress behaviors related to sleep-wake states, 10 self-regulatory behaviors, and 17 behavioral stress cues) in preterm infants during periods of environmental stress. This research used a prospective repeated-measures design in a convenience sample of preterm infants of <37 weeks' gestational age and <28 days' postnatal age. All infants were in the incubator in a neonatal intensive care unit or a sick baby care unit in one of two hospitals at the time of data collection. Multiple linear regressions of generalized estimating equations were used to determine relationships. Variables were measured every 2 min over 4 hr, for a total of 4,164 observations in 37 preterm infants. There were statistically significant relationships between 9 stress behavioral responses and changes in HR (seven stress behaviors and two self-regulatory behaviors; p < .05), between 9 stress behavioral responses and changes in RR (seven stress behaviors and two self-regulatory behaviors; p < .05), and between 11 stress behavioral responses and changes in oxygen saturation (seven stress behaviors and four self-regulatory behaviors; p < .05). Findings demonstrate that the functions of self-regulatory behaviors and some special behaviors in preterm infants during environmental stress are related to physiological stress signals. However, results should be investigated further in larger samples.

Pain management during retinopathy of prematurity eye examinations: a systematic review

Retinopathy of prematurity (ROP) remains a concern for many preterm infants. Early detection and timely treatment have been shown to be effective in improving visual outcomes; moreover, it is crucial that a series of indirect ophthalmic examinations be performed until an infant is considered no longer at risk for the disease. The purpose of this systematic review is to summarize and evaluate the published evidence regarding characteristics and effectiveness of pain management interventions during the ROP examination. Implications for practice are discussed and suggestions for further research are made. Despite the general consensus that ROP examination is a painful procedure with considerable amount of discomfort, evidence shows that pain management during the ROP examination is inadequate. Although there are currently clear recommendations and guidelines for performing the ROP examination, there are no standard protocols for pharmacological and nonpharmacological pain management during the ROP examination. This is an area where much work is still needed to address the needs of the infant during this critical examination.

Cerebellar hemorrhage in extremely low birth weight infants: incidence, risk factors, and impact on long-term outcomes

Improvements in neuroimaging technology and techniques have contributed to the increased recognition of cerebellar hemorrhage (CBH) in the prererm infant. Studies have indicated that the extremely low birth weight (ELBW) infant (< 1,000 g) is at highest risk for this injury. Associated risk factors include a constellation of antenaral, intrapartum, and neonatal factors, with immaturity, fetal distress, and cardiorespiratory instability in the early neonatal course as significant contributors. The long-term impact of CBH for the ELBW infant is not fully understood, but recent reports suggest that, in addition to motor impairments, deficits in cognitive, language, and social-behavioral function are also apparent. This article reviews the current state of knowledge of cerebellar development, risk factors for injury, and long-term developmental consequences of injury. Implications for nursing practice, education, and research are discussed.

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.

FETAL PAIN

The concept of fetal pain is becoming more and more relevant since the possibilities for invasive intrauterine treatment are increasing. However, there is much debate as to whether the fetus is mature enough to be able to perceive pain. But what is ‘pain’? One cannot determine whether a fetus feels pain unless one has a conception of what pain is. There is a difference in opinion about what pain really is and that is also the difficulty in studies on fetal pain: we cannot simply ask the fetus whether or not it feels pain. We can only give indirect evidence of possible harmful effects of stressful stimuli on the developing fetus. In this review we will first explore the meaning of ‘pain’. We will then discuss fetal anatomic, neurophysiologic and behavioural development and the responses which are thought to be required to experience pain. Finally, we discuss some ethical considerations and suggestions on fetal anaesthesia.

Behavioral stress is affected by the mode of tube feeding in very low birth weight infants

OBJECTIVE

To compare the effect of continuous versus bolus feeding on behavioral responses of stress in very low birth weight infants during early postnatal life.

METHODS

In a randomized, controlled trial conducted at 3 neonatal units, 70 premature infants with gestational age 24 to 29 weeks and birth weight <1200 g were randomly assigned to 1 of 3 feeding methods: continuous nasogastric feeding, bolus nasogastric feeding, and bolus orogastric feeding. Behavioral responses were video recorded during feeding at 7 and 15 days of postnatal age and at 32 weeks of postmenstrual age. The odds ratio (OR) of manifest behavioral stress was calculated by means of logistic regression.

RESULTS

A significantly higher risk of a behavioral stress response in bolus-fed infants compared with continuous-fed infants at 15 days of age was observed, [adjusted OR=4.1 (95% confidence interval: 1.1-15.4)]. A similar difference was observed at 32 weeks of postmenstrual age [adjusted OR=4.2 (95% confidence interval: 1.0-17.8)]. In addition, bolus-fed infants showed statistically significant higher need of behavioral and physiologic stabilization during feeding.

DISCUSSION

This trial suggests that continuous feeding is associated with lower behavioral stress response as compared with bolus feeding among very low birth weight infants, in early postnatal life.

Pain behaviours in Extremely Low Gestational Age infants

BACKGROUND

To date, there are over 40 infant pain measures. Despite this plethora of measures, only 8 have included preterm infants and only 2 have included Extremely Low Gestational Age (ELGA; infants <28 weeks GA) in their development. Without reliable, valid and clinically useful indicators for procedural pain in ELGA infants, clinicians have no means to interpret the responses from an immature infant who may respond differently from infants of older GA.

OBJECTIVE

To examine the physiological, behavioural and biochemical responses to painful and non-painful procedures in ELGA infants and the influence of GA and sex.

DESIGN/METHODS

A prospective crossover design with 50 ELGA infants from one Canadian tertiary level NICU was conducted. Infants were assessed in random order during standardized painful (heel lance) and non-painful (diaper change) procedures. Physiological (heart rate, oxygen saturation) and behavioural (facial and body movement) indicators were continuously collected during 4 phases of the procedures. Biochemical (salivary cortisol) indicators were collected immediately before and 20 min following the procedures.

RESULTS

Four facial actions (brow bulge, eye squeeze, nasolabial furrow, vertical mouth stretch) increased immediately following the heel lance. There were no specific changes in physiological, body movement or cortisol indicators following the heel lance. ELGA infants demonstrated greater body movements during the diaper change, which may reflect immature motor coordination. No differences in pain responses were found for infants born between 23-25 6/7 weeks GA and those between 26-28 weeks GA. Similarly, no gender differences were found.

CONCLUSIONS

Changes in 4 facial actions were the most sensitive indicators of pain in ELGA infants. This finding is consistent with existing measures where facial actions are the most prominent pain indicators. Specific body movements such as those included in NIDCAP, may provide more information about pain in ELGA infants. Movements such as hand-on-face, finger splaying, fisting, arching or yawning need to be examined in future research.

Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) scale

OBJECTIVES

To evaluate the ability of the Behavioral Indicators of Infant Pain (BIIP) scale to discriminate between skin-breaking and nonskin breaking procedures, and to identify sensitized pain responses in preterm infants in the neonatal intensive care unit (NICU).

METHODS

Sixty-nine infants born between 24 and 32 weeks gestational age were assessed at 32 weeks postconceptional age during blood collection on one day (procedure A), and then on another day during blood collection preceded by a diaper change (procedure B). Procedure order was randomized. Outcome measures were changes in BIIP coded from continuous bedside video recordings and changes in heart rate (HR).

RESULTS

During blood collection (procedure A), BIIP scores (P<0.0001) and mean HR (P<0.0001) were higher than during the diaper change and higher when the infants had had a preceding diaper change (procedure B vs. procedure A) (P<0.03). HR changed from baseline to the stressors for each procedure. No differences in mean HR were observed during Lance phase between the procedure A and the B blood collection; however, HR remained elevated significantly during the Recovery phase when blood collection was preceded by the diaper change (P<0.03).

DISCUSSION

The BIIP scale is reliable, accurate, and valid assessment for measuring acute pain in preterm infants in the NICU. This assessment combines the relatively most specific, anatomically based, theoretically derived indicators; and it allows evaluation of behavioral and physiologic pain responses separately.

Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain

OBJECTIVE

To establish beginning evidence of clinical validity and reliability of the Neonatal Pain, Agitation and Sedation Scale (N-PASS) in neonates with prolonged pain postoperatively and during mechanical ventilation.

STUDY DESIGN

Prospective psychometric evaluation. Two nurses administered the N-PASS simultaneously and independently before and after pharmacologic interventions for pain or sedation. One nurse also administered the premature infant pain profile (PIPP) concurrently with the N-PASS. The setting consisted of 50-bed level III neonatal intensive care unit. Convenience sample of 72 observations of 46 ventilated and/or postoperative infants, 0 to 100 days of age, gestational age 23 to 40 weeks was used. Outcome measures comprised convergent and construct validity, interrater reliability and internal consistency.

RESULT

Interrater reliability measured by intraclass coefficients of 0.85 to 0.95 was high (P<0.001 to 0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman's rank correlation coefficient of 0.83 at high pain scores, 0.61 at low pain scores). Internal consistency, measured by Cronbach's alpha, was evident with pain scores (0.82), and with sedation scores (0.87). Construct validity was established via the Wilcoxon signed-rank test, comparing the distribution of N-PASS scores before and after pharmacologic intervention showing pain scores of 4.86 (3.38) and 1.81 (1.53) (mean (s.d.), P<0.0001) and sedation scores of 0.85 (1.66) and -2.78 (2.81) (P<0.0001) for pre- and postintervention assessments, respectively.

CONCLUSIONS

This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing pain/agitation and sedation in ventilated and/or postoperative infants 0 to 100 days of age, and 23 weeks gestation and above.

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Accurate pain assessment in preterm infants in the neonatal intensive care unit (NICU) is complex. Infants who are born at early gestational ages (GA), and who have had greater early pain exposure, have dampened facial responses which may lead to under-treatment. Since behavioral and physiological responses to pain in infants are often dissociated, using multidimensional scales which combine these indicators into a single score may limit our ability to determine the effects of interventions on each system. Our aim was to design a unidimensional scale which would combine the relatively most specific, individual, behavioral indicators for assessing acute pain in this population. The Behavioral Indicators of Infant Pain (BIIP) combines sleep/wake states, 5 facial actions and 2 hand actions. Ninety-two infants born between 23 and 32 weeks GA were assessed during 3, 1 min Phases of blood collection. Outcome measures included changes in BIIP and in Neonatal Infant Pain Scale (NIPS) scores coded in real time from continuous bedside video recordings; changes in heart rate (HR) were obtained using custom physiological processing software. Scores on the BIIP changed significantly across Phases of blood collection (p<0.01). Internal consistency (0.82) and inter-rater reliability (0.80-0.92) were high. Correlations between the BIIP and NIPS were modest (r=0.64, p<0.01) as were correlations between the BIIP and mean heart rate (r=0.45, p<0.01). In this initial study, the BIIP has been shown to be a reliable, valid scale for assessing acute pain in preterm infants in the NICU.

Do ventilated neonates require pain management?

Mechanical ventilation is a stressful experience in neonates resulting in changes in neuroendocrine parameters, pain scores, and physiologic responses. Assisted ventilation in neonates is presumed to be associated with chronic repetitive pain, which in turn is associated with adverse long-term sequelae. Reasons to routinely sedate ventilated neonates include improved ventilator synchrony, improved pulmonary function, and decreased neuroendocrine responses, including cortisol, beta-endorphine, and catecholamines. Reasons not to treat include the well-known adverse side effects of pain medication, especially the opiates, including hypotension from morphine, chest wall rigidity from fentanyl, and tolerance, dependence, and withdrawal from both opiates and benzodiazepines. Additionally, adverse effects such as death and IVH are not improved with preemptive treatment. Chronic pain assessment is poorly validated and difficult to assess in this population, and most studies have evaluated only acute pain scores. If patients are treated, opiates are the most common class of drugs, with morphine the most well studied. Fentanyl may be advantageous in hypotensive, younger neonates because it has fewer cardiovascular effects. The benzodiazepines, midazolam and lorazepam, have been used in ventilated neonates, but midazolam has been associated with adverse effects in one small study so concern remains regarding its use. Significant gaps in our knowledge exist, especially in regard to long-term effects of treatment, or lack thereof, and in the assessment of the chronic pain associated with assisted ventilation.

Prevention and management of pain in the neonate. An update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Relationships between adrenocorticotropic hormone and cortisol are altered during clustered nursing care in preterm infants born at extremely low gestational age

BACKGROUND

Little is known about the effects of clustered nursing care on hypothalamic pituitary axis (HPA) responses in preterm infants in the neonatal intensive care unit.

AIMS

To examine facial responses, adrenocorticotropic hormone (ACTH) and cortisol levels, and the relationship between ACTH and cortisol in preterm infants in two gestational age groups (extremely low gestational age [ELGA: < or =28 weeks]; very low gestational age [VLGA: 29-31 weeks]) under basal conditions and in response to routine nursing procedures.

STUDY DESIGN

Within subjects' cross-over design in random order.

SUBJECTS

Ninety preterm infants with no postnatal steroid exposure were studied at 32+/-1 weeks postconceptional age.

OUTCOME MEASURES

Facial actions, ACTH and cortisol levels were measured after a 30 minute rest period and in response to routine clustered nursing care (CC). Changes in facial actions were analyzed using repeated measures ANOVA. MANOVA or Mann-Whitney U tests were used to determine differences in ACTH and cortisol between gestational age groups. Spearman rank correlations were used to examine relationships between perinatal variables and facial, ACTH and cortisol levels.

RESULTS

All infants had significantly increased facial responses to CC (p=0.001). Infants having experienced higher numbers of skin breaking procedures 24 h before basal assessment had higher basal cortisol levels (r=0.30, p=0.01). In response to CC, ELGA infants showed no correlation between ACTH and cortisol levels; VLGA infants showed a strong, positive correlation (r=0.62, p=0.02).

CONCLUSION

The pattern of relationship between ACTH and cortisol differs depending on gestational age at birth in response to clustered nursing care. Prior pain alters responsiveness and HPA dysregulation is apparent in ELGA infants.

Testing the satisfaction and feasibility of a computer-based teaching module in the neonatal intensive care unit

PURPOSE

To examine the satisfaction with and feasibility of a computer-based teaching module to teach healthcare professionals how to use and apply the Premature Infant Pain Profile (PIPP) to clinical scenarios.

SUBJECTS

Sixty-eight healthcare professionals who were employed in the neonatal intensive care unit (NICU) on a full-time or part-time basis and had received an educational session regarding the PIPP.

DESIGN AND METHODS

A pilot study using an exploratory descriptive design was used to answer: (1) How satisfied are healthcare professionals with the computer-based teaching module? and (2) What is the feasibility of a computer-based teaching module in the clinical setting? Satisfaction was measured using an investigator-developed 5-point Likert scale. Feasibility was measured in terms of time to complete the module, satisfaction with instructions and ability to navigate through the module, acceptability of the module as a teaching method, and format with the computer-based module.

PRINCIPAL RESULTS

Ninety percent of those sampled were very satisfied with the computer-based teaching method. Use of video and audio clips and photographs enhanced the learning process. Healthcare professionals identified the computer-based teaching method as an effective way of learning about the PIPP and thought that it was feasible to use within the clinical setting.

CONCLUSIONS

Computer-based teaching is a feasible method for educating NICU healthcare professionals about the PIPP. Additional research is required to examine the effectiveness of this teaching method on relevant patient outcomes such as pain management.

Behavioral responses to pain are heightened after clustered care in preterm infants born between 30 and 32 weeks gestational age

OBJECTIVE

To compare biobehavioral pain responses of preterm infants born at differing gestational ages (GAs) when pain was preceded by a rest period or by a series of routine nursing interventions.

METHODS

In a randomized, within subjects, cross-over design, facial (Neonatal Facial Coding System), sleep/wake state and heart rate (HR) responses of 43 preterm infants [mean birth weight: 1303 g (range 590 g to 2345 g); mean GA at birth: 30 weeks (range 25 to 32)] were examined across 3 phases of blood collection (Baseline, Lance, and Recovery) under 2 conditions: pain after a 30-minute rest period versus pain after a series of routine nursing interventions (clustered care). Infant behavioral responses were coded from continuous bedside videotapes. HR was analyzed using custom physiologic signal processing software.

RESULTS

Infants born at earlier GA (<30 wk) had equally intense facial responses during the Lance phase regardless of condition. However, later born infants (> or =30 wk GA) showed heightened facial responses indicative of sensitized responses during blood collection when it was preceded by clustered care (P=0.05). Moreover, later born infants had significantly lower facial (P=0.05) and HR (P=0.04) reactivity during Recovery when blood collection followed clustered care.

DISCUSSION

Earlier born preterm infants showed heightened states of arousal and poor ability to modulate HR during Recovery when an invasive procedure was preceded by routine tactile nursing procedures. Alternatively, later born infants exhibited sensitized responses when clustered care preceded blood collection. Our findings support the importance of cue based individualized approaches to care.

Prevention and management of pain in the neonate: an update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Pain perception development and maturation

Newborn infants are not small adults. The pharmacokinetics and dynamics of analgesic drugs are immature at birth. Volumes of distribution, drug clearances, side-effects and drug efficacy all differ in newborns as compared to adults. Interestingly, these parameters develop before birth and during the postnatal period, reaching adult values after a period of months or years. This means that clinicians should anticipate on pharmacokinetic/pharmacodynamic (PK/PD) changes in newborns with increasing post-conceptual age. The ability to perceive pain might also be immature at birth. Lower pain thresholds due to the absence of inhibitory descending spinothalamic fibers and a not yet fully developed cortical pain memory system are points of interest for our understanding of differences in pain perception in the newborn infant. Although this is a relatively unexplored area of research in humans, we will discuss the maturation and development of neonatal pain experience and perception in this paper.

Pain assessment: current status and challenges

Neonatal pain assessment has received much attention over the past decade. Behavioural indicators of pain include facial action, body movement and tone, cry, state/sleep, and consolability. Physiological indicators of pain include increased heart rate, respiratory rate, and blood pressure, as well as decreased heart rate variability and oxygen desaturation. Pain assessment in neonates is difficult in neurologically compromised, chemically paralyzed, and non-responsive infants. Multiple pain assessment tools are summarized. Pain assessment and management protocols are delineated.

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.

Body Movements: An Important Additional Factor in Discriminating Pain From Stress in Preterm Infants

OBJECTIVES

To describe developmentally appropriate, specific body movements and other biobehavioral responses of preterm infants to a group of routine care giving tasks (Clustered Care), and to compare responses to acute pain with those of Clustered Care.

METHODS

In a randomized design, 54 preterm infants were assessed at 32 weeks gestational age during 3 phases of blood collection (Baseline, Lance/squeeze, Recovery) and of diaper changing, measuring abdominal girth and axillary temperature, and mouth care (Baseline, Clustered Care, Recovery) in a neonatal intensive care unit. The Newborn Individualized Developmental Care and Assessment Program and 1 facial action from the Neonatal Facial Coding System, Brow Bulge, were coded from separate continuous bedside video recordings. Heart rate and oxygen saturation were also acquired continuously.

RESULTS

Brow Bulge, heart rate, and a subset of 9 Newborn Individualized Developmental Care and Assessment Program movements increased and oxygen saturation decreased significantly to Lance/squeeze compared to Baseline. Similar facial and physiological changes occurred during Clustered Care, but with less intensity. However, infants showed greater frequencies and variety of Newborn Individualized Developmental Care and Assessment Program stress cues during Clustered Care than during Lance/squeeze. Stress cues persisted after Clustered Care, whereas the infants returned to Baseline following Lance/squeeze.

DISCUSSION

Changes in facial activity and heart rate remain the most sensitive markers of pain in preterm infants. Tactile procedures, such as diaper changing, produce lower intensity facial and physiological responses than pain procedures, but greater body reactions. Also, the effects from tactile procedures appear to last longer. Adding observations of a small number of specific body movements to the assessment of pain and stress provides complementary information particularly for those infants who may show dampened facial reactivity as a result of repeated pain exposure.

Prior pain induces heightened motor responses during clustered care in preterm infants in the NICU

BACKGROUND

Acute pain is a significant stressor for preterm infants in neonatal intensive care units (NICU); however, little is known about the effects of acute pain on subsequent motor responses during clusters of tactile handling.

AIMS

(1) To compare facial, body and heart rate reactivity in preterm infants at 32 weeks gestational age (GA) during routine care-giving tasks following a rest period (RCC: diapering, measuring abdominal girth and axillary temperature, mouth care) with their responses to Clustered Care following blood collection (PCC). (2) To examine how GA at birth affects patterns of stress and self-regulatory behaviors during RCC and PCC.

STUDY DESIGN

Within-group crossover design (random order).

SUBJECTS

Preterm infants, N=54 (mean GA at birth 29.3 +/- 2.2 weeks; mean birth weight 1257 +/- 423 g) were assessed at 32 weeks GA in the NICU.

OUTCOME MEASURES

The Newborn Developmental Care and Assessment Program (NIDCAP) and Neonatal Facial Coding System (NFCS) were coded from continuous bedside video recordings. Changes in mean heart rate (HR) were computed using custom physiologic software.

RESULTS

All infants had heightened facial, body and HR responses when CC followed a painful procedure compared to when they had not been handled prior to CC. Infants born at earlier GA (<30 weeks) had equal numbers of stress cues during RCC and PCC, but dampened self-regulatory behaviors during PCC.

CONCLUSION

Prior pain induces heightened biobehavioral reactivity in preterm infants during subsequent tactile procedures. In addition, clustering care is particularly stressful for infants born at earlier GA.

A reliable pain assessment tool for clinical assessment in the neonatal intensive care unit

OBJECTIVE

The aim of this study was to validate a clinician-friendly pain assessment tool for all groups of critically ill infants cared for in the specific neonatal intensive care units (NICUs) studied.

DESIGN

A prospective study was undertaken to test the Pain Assessment Tool (PAT). Interrater reliability of the PAT score was assessed by two nurses who simultaneously determined an infant's PAT score. The PAT was validated against the CRIES score--crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness--and the mother's assessment of her infant's discomfort using the Visual Analogue Scale (VAS).

SETTING

The NICUs at two children's hospitals.

PATIENTS

Participants were 144 preterm and term infants. Infants on a ventilator and those who had undergone surgery were included.

RESULTS

The interrater reliability of the PAT was .85 with a mean difference of 0.17 (standard deviation: 1.73). There was a strong correlation between the PAT and CRIES scores (r = 0.76) and a moderate correlation (.38) between the PAT score and the VAS scores of the infant's mother. The correlation coefficient between the PAT score and CRIES score was significant for all groups (p < .01).

CONCLUSIONS

The PAT score was shown in this study to be a valid, reliable, and clinician-friendly pain assessment measurement tool for all infants nursed in the NICU.

The nature of touch in mothers experiencing maternity blues: the contribution of parity

BACKGROUND

Maternal touch (MT) is an essential part of the initial contact between the mother and her newborn and has developmental effects on the child. MT is known to be reduced in postpartum depression (PPD). The nature of MT in mothers experiencing maternity blues and the effect of parity are still unknown.

STUDY DESIGN

Seventy-five mothers were recruited from the ongoing series of deliveries.

SUBJECTS

The participating mothers were observed during interaction with their newborns on the second-day postpartum. Touching behavior was scored on-line according to the Touch Scoring Instrument, which includes nine types of MT. Mothers were categorized as exhibiting maternal blues according to Stein's depression scale.

OUTCOME MEASURE

Touch Scoring Instrument.

RESULTS

Primiparous mothers with blues avoided all types of touch whereas multiparous mothers with blues provided firm touch and holding. All mothers with blues avoided proprioceptive touch. Multiparous mothers without maternal blues provided various types of touch including affectionate holding and matter-of-fact touch whereas primiparous mothers without blues mostly provided holding.

CONCLUSIONS

Mothers with maternity blues on day 2 exhibited a pattern of MT similar to that known to characterize postpartum depression. Mothers without blues are able to provide developmental touch in a manner known to facilitate CNS stability and newborn adjustment to the extra-uterine world. Parity modulates the effect of maternity blues on MT and buffers the withdrawal effect of depression. Maternal touch could be used as a diagnostic tool for detection of mothers at risk in a timely manner. Touch interventions, which were previously demonstrated in PPD mothers, may be utilized in an earlier stage postpartum.

Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit

OBJECTIVE

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants.

METHODS

Forty-four preterm infants were assessed at 32 weeks' gestational age (GA) during 3 phases (baseline, lance/squeeze, and recovery) of routine blood collection in the neonatal intensive care unit. The NIDCAP and Neonatal Facial Coding System (NFCS) were coded from separate continuous bedside video recordings; mean heart rate (mHR) was derived from digitally sampled continuous electrographic recordings. Analysis of variance (phase x gender) with Bonferroni corrections was used to compare differences in NIDCAP, NFCS, and mHR. Pearson correlations were used to examine relationships between the NIDCAP and infant background characteristics.

RESULTS

NFCS and mHR increased significantly to lance/squeeze. Eight NIDCAP behaviors also increased significantly to lance/squeeze. Another 5 NIDCAP behaviors decreased significantly to lance/squeeze. Infants who had lower GA at birth, had been sicker, had experienced more painful procedures, or had greater morphine exposure showed increased hand movements indicative of increased distress.

CONCLUSIONS

Of the 85 NIDCAP behaviors, a subset of 8 NIDCAP movements were associated with pain. Particularly for infants who are born at early GAs, addition of these movements to commonly used measures may improve the accuracy of pain assessment.

Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial

BACKGROUND

Opioid analgesia is commonly used during neonatal intensive care. We undertook the Neurologic Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) trial to investigate whether pre-emptive morphine analgesia decreases the rate of a composite primary outcome of neonatal death, severe intraventricular haemorrhage (IVH), and periventricular leucomalacia (PVL) in preterm neonates.

METHODS

Ventilated preterm neonates (n=898) from 16 centres were randomly assigned masked placebo (n=449) or morphine (n=449) infusions. After a loading dose (100 microg/kg), morphine infusions (23-26 weeks of gestation 10 microg kg(-1) h(-1); 27-29 weeks 20 microg kg(-1) h(-1); 30-32 weeks 30 microg kg(-1) h(-1)) were continued as long as clinically justified (maximum 14 days). Open-label morphine could be given on clinical judgment (placebo group 242/443 [54.6%], morphine group 202/446 [45.3%]). Analyses were by intention to treat.

FINDINGS

Baseline variables were similar in the randomised groups. The placebo and morphine groups had similar rates of the composite outcome (105/408 [26%] vs 115/419 [27%]), neonatal death (47/449 [11%] vs 58/449 [13%]), severe IVH (46/429 [11%] vs 55/411 [13%]), and PVL (34/367 [9%] vs 27/367 [7%]). For neonates who were not given open-label morphine, rates of the composite outcome (53/225 [24%] vs 27/179 [15%], p=0.0338) and severe IVH (19/219 [9%] vs 6/189 [3%], p=0.0209) were higher in the morphine group than the placebo group. Placebo-group neonates receiving open-label morphine had worse rates of the composite outcome than those not receiving open-label morphine (78/228 [34%] vs 27/179 [15%], p<0.0001). Morphine-group neonates receiving open-label morphine were more likely to develop severe IVH (36/190 [19%] vs 19/219 [9%], p=0.0024).

INTERPRETATION

Pre-emptive morphine infusions did not reduce the frequency of severe IVH, PVL, or death in ventilated preterm neonates, but intermittent boluses of open-label morphine were associated with an increased rate of the composite outcome. The morphine doses used in this study decrease clinical signs of pain but can cause significant adverse effects in ventilated preterm neonates.

The relationship between physiological and behavioral measures of stress in preterm infants

OBJECTIVE AND DESIGN

The purpose of this exploratory descriptive analysis was to explore relationships among physiological stress, behavioral stress, and motor activity cues in preterm infants when they were not being handled or disturbed, and to determine whether there were differences between younger and older preterm infants in these variables or relationships.

SETTING AND PARTICIPANTS

The convenience sample included 42 preterm infants who had been 27 to 33 weeks gestational age at birth and were from 6 to 19 days old at the time of data collection in the neonatal intensive-care unit.

MEASURES

In each 10-minute observation, heart rate (HR) and oxygen saturation (O2 sat) levels were recorded every 5 seconds, and observational measures of behavioral distress and motor activity were recorded twice a minute. The physiological data were coded to reflect the percentage of each 10-minute period during which HR levels were less than 100 bpm or more than 200 bpm or O2 sat levels were abnormally low (less than 90 mg%). Data were analyzed with correlational and general linear mixed models procedures.

RESULTS

Stress cues and motor activity were more often related to low levels of O2 sat than to low or high HR. Physiological status was more often related to motor activity than to stress cues. Few differences in the relationships were observed between younger and older preterm infants.

CONCLUSION

Although these results are preliminary, they suggest that neonatal nurses should monitor preterm infants' behavioral stress and motor activity cues in response to caregiving and minimize stimuli that evoke stress responses linked to physiological instability.